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anaphylaxis management per theAssociation of Anaesthetists of GreatBritain and Ireland guidelines [1]. Bron-chospasm, the predominant clinical fea-

ture, was so severe it necessitateddisconnection of the breathing circuit

and manual compression of the chestwall to facilitate exhalation.

Following a positive response totreatment, a decision to proceed withsurgery was made together with theneurosurgeons. Despite an increasedrisk of coagulopathy associated withanaphylaxis, the team felt that the needto preserve hand function, which wasbeing compromised by the tumour, justified the fact that we proceeded tosurgery. Surgery was uneventful. Thepatients trachea was extubated success-fully the following morning.

Tryptase and complement levelswere all normal; however, this doesntrule out anaphylaxis [1]. Skin pricktesting for neuromuscular blockerscefuroxime, propofol, lidocaine, remif-entanil and latex were performed, all ofwhich were subsequently negative.With hindsight, we suggest that move-ment of the tracheal tube duringinsertion of the throat pack precipitated

bronchospasm, and the high inflationpressures with auto-PEEP resulted inreduced venous return, hypotension

and cardiovascular collapse, thusmimicking anaphylaxis.We conducted an internal survey of

all anaesthetists in the Leeds GeneralInfirmary asking them about the timingof administration of intravenous anti-biotics in theatre and also to rank the

anaphylactic risk of various neuro-muscular blockers. One hundredresponded (an 83% response rate).Although 25% of respondents believedantibiotics should be given more than30 min before induction, only 15%administer them before and 5% give

them with induction agents. Previously,the Association of Anaesthetists of GreatBritain and Ireland has recommendedthat antibiotic administration should beseparated from induction [2], therebyallowing the normal haemodynamicchanges at induction of anaesthesia toresolve, yet over 70% of respondentsadminister antibiotics within 10 min ofinduction.

Anaphylaxis under anaesthesia is rare,but in 60% of cases neuromuscularblocking drugs are the causative agentsandin only15% areantibioticsat fault [1].

Our assumption that cefuroxime ratherthan vecuronium was the precipitant was

therefore likely to have been incorrect.Suxamethonium is the most likely of theneuromuscular blockers to cause ana-phylaxis, followed by rocuronium [3].Twenty-five percent of those surveyedfailed to rank suxamethonium as thehighest-risk agent and 40% thoughtrocuronium to be low-risk. Whethersugammadex will increase rocuroniumsuse waits to be seen, but clearly anaes-thetists underrate its allergic potential.

Like theanaesthetists in thecaseabove,most respondents regarded vecuroniumas the safest neuromuscularblocking drug

(38%) or ranked it 5th or lower, out of 7agents (65%). This is not in accordancewith the literature which gives vecuro-nium medium risk [3]. Even though

cis-atracurium was regarded as the safestagent by 27% it is only used by 2% of

respondents.This incident highlights how the

deleterious effects of gas trapping duringbronchospasm can masquerade as

anaphylaxis. In addition, our surveysuggests that anaesthetists are poorlyinformed regarding the anaphylactic

potential of neuromuscular blockingdrugs, and that the choice of the latteris not guided by concerns over anaphy-lactic risk. The administration of anti-biotics, at induction, is at variance withboth ideal practice and guidance.

A. Kant

J. McKinlay

Leeds General Infirmary

Leeds UK

E-mail: justin.mckinlay@leedsth.nhs.uk

References

1 The Association of Anaesthetists ofGreat Britain and Ireland. Guidelines

Suspected Anaphylactic Reactions Associ-

ated with Anaesthesia. 2009. http://

aagbi.org/publications/guidelines/

docs/anaphylaxis_2009.pdf (accessed

11 10 09).

2 The Association of Anaesthetists of

Great Britain and Ireland. Guidelines

Suspected Anaphylactic Reactions Associ-

ated with Anaesthesia. London, UK:

AAGBI, 2003.

3 Laxenaire MC, Mertes PM; Groupe

dEtudes des Reactions Anaphylac-

todes Peranesthesiques. Anaphylaxis

during anaesthesia. Results of a two-

year survey in France. British Journal ofAnaesthesia 2001; 87: 54958.

Subcostal transversusabdominis plane block

We would like to describe a case inwhich we successfully used a subcostal

transversus abdominis plane block in afrail elderly patient requiring a defunc-tioning ileostomy. The patient had very

limited exercise tolerance and presentedon the emergency list. Following a CT

scan of the abdomen, a diagnosis of smallbowel obstruction was made, with astricture in the area of the ileocaecalvalve. The patient was warfarinised foratrial fibrillation and had a pre-operativeINR of > 10. The surgeons wished toperform a defunctioning ileostomy usingan incision in the right upper quadrant.

This patient was high-risk due to hersignificantly limited physiologicalreserve. After discussion, she declinedthe option of postoperative admission tothe Intensive Care Unit (ICU). Tho-racic epidural placement was unsuitabledue to the high INR. It was agreedwith the patient that the procedurecould be performed under local anaes-thesia and sedation, and if this wasunsuccessful, she would be for conser-vative management only. We consid-ered using a transversus abdominis planeblock [1, 2] to provide analgesia; how-ever, if conventionally performed, itwould only provide a reliable block forincisions to the level of T8. Following aliterature search an alternative tech-nique described by Hebbard [3, 4], the

subcostal transversus abdominis planeblock, used to provide effective analge-sia for a cholecystectomy incision, waschosen as a potential solution.

Following correction of her INRwithvitamin K and 1500 IU prothrombincomplex concentrate, we performed the

subcostal transversus abdominis planeblock following Hebbards description,under ultrasound [5] (Fig 1). In contrast

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to the more familiar transversus abdo-minis plane block the subcostal block isperformed at the costal margin withhydro-dissection of the appropriate planecaudally. We used 20 ml 0.5% levobup-ivicaine and the block was confirmedwith loss of sensation to ice. A low-dose

remifentanil infusion (0.1 lg.kg.min)1)was commenced to cover visceral stim-ulation and the rate was gradually

reduced to 0.02 lg.kg.min)1 during

the procedure. The patient was comfort-ablethroughout and we areconfidenttheblock provided sufficient analgesia for

the large initial incision and dissection tothe small bowel. The patient made anexcellent recovery.

K. OConnor

C. Renfrew

Ulster Hospital

Belfast, UK

E-mail: kieranoconnor@doctors.org.uk

References

1 Carney J, McDonnell JG, Ochana A,Bhinder R, Laffey JG. The transversus

abdominis plane block provides effec-

tive postoperative analgesia in patients

undergoing total abdominal hysterec-

tomy. Anesthesia and Analgesia 2008;

107: 205660.

2 McDonnell JG, ODonnell B, Curley

G, Heffernan A, Power C, Laffey JG.

The analgesic efficacy of transversus

abdominis plane block after abdominal

surgery: a prospective randomized

controlled trial. Anesthesia and Analgesia

2007; 104: 1937.

3 Hebbard P, Fujiwara Y, Shibata Y,

Royse C. Ultrasound-guided transver-

sus abdominis plane (TAP) block.

Anaesthesia and Intensive Care2007; 35:

6167.

4 Tran TM, Ivanusic JJ, Hebbard P,

Barrington MJ. Determination of

spread of injectate after ultrasound-guided transversus abdominis plane

block: a cadaveric study. British Journal

of Anaesthesia 2009; 102:

1237.

5 Hebbard P. http://usra.ca/UIA/

Getfile.php/id=30 (accessed

09 09 09).

Peri-operative echocardio-

graphic diagnosis of aorticstenosis

McBrien et al. [1] recently analysed themanagement and outcome of 272patients identified with previouslyundiagnosed aortic stenosis before hipfracture surgery. We congratulate theauthors on reporting this large series of

patients with aortic stenosis undergoingnoncardiac surgery.

Degenerative aortic valve disease is

common and closely correlated with

ageing. The definitive treatment forsevere aortic stenosis is valve replace-ment, which improves symptoms andprognosis. Age itself is not a contrain-

dication to surgery; operative mortalityis low but is higher in patients with

comorbid conditions. Non-operativetreatment of aortic stenosis carries apoor prognosis.

Despite the favourable results ofsurgical aortic valve replacement, manypatients with severe, symptomatic aorticstenosis are not offered surgery. TheEuro Heart Survey found that a deci-sion not to operate was taken in 33% of216 patients aged 75 years and overwith severe, symptomatic aortic stenosis[2]. McBrien et al. did not report thenumber of patients with aortic stenosiswho progressed to valve replacement

during the follow-up period, whichwould be an interesting addition totheir study.

The new evolving technique oftranscatheter aortic valve implantationprovides an alternative, less invasivetreatment for aortic stenosis, avoidingthe need for median sternotomy andcardiopulmonary bypass [3]. The pro-cedure is safe and effective in the short-

term; long-term outcome data areemerging [4]. High-risk patients withconcomitant illnesses not suitable for

surgical aortic valve replacement maynow be offered transcatheter aorticvalve implantation. Therefore, as the

techniques and indications for lessinvasive treatment of aortic stenosiscontinue to evolve, the timely diagnosisof the disease will become even more

important.McBrien et al. rightly call for ade-

quately resourced echocardiographyservices so that pre-operative echo-cardiography in hip fracture patientswith suspected aortic stenosis does notdelay operative fracture fixation. Delay-

ing surgery beyond 48 h after admissionwith hip fracture may increase 30-dayand 1 year all-cause mortality [5]. Wesuggest that valvular intervention in hipfracture patients with severe aorticstenosis should not delay surgery and isoptimally performed after hip fracturefixation.

We support McBrien et al. and rec-ommend early identification of aortic

Figure 1 Needle and probe position for ultrasound guided subcostal transversusabdominis plane block (Diagram kindly provided by Dr P Hebbard).

Correspondence Anaesthesia, 2010, 65, pages 8293......................................................................................................................................................................................................................

92 2009 The Association of Anaesthetists of Great Britain and Ireland