Propofol-induced anaphylactoid reaction during anesthesia for cardiac surgery.

A 51-year-old man with a history of unstable angina was scheduled for CABG surgery. He had no history of a prior general anesthetic or allergies. He sustained a Q-wave inferior myocardial infarction 12 years ago, and his ejection fraction was 54%. Current medications were nisoldipine, 5 mg, a calcium channel blocker; celiprolol, 200 mg, a P-blocker; and m&dine, 150 mg, as well as a continuous intravenous nitroglycerin infusion at a rate of 4 pglkglmin. One hour before induction, the patient was premeditated with morphine sulfate, 8 mg intramuscularly, glycopyrrolate, 0.2 mg intramuscularly, and ranitidine, 50 mg intravenously. In the operating room, in addition to standard monitors, a 5-lead electrocardiogram (ECG) and a pulse oximeter were placed. A 16-gauge catheter and 20-gauge catheter were placed in a peripheral vein and radial artery under local anesthesia. Before induction, blood pressure was 140/61 mmHg, and heart rate was 62 beats/min. After preoxygenation, a propofol infusion was started at an initial rate of 0.8 pg/kg/min. Three minutes later, the patient received a bolus of 25 pg of sufentanil and a priming dose of 0.5 mg of pancuronium. The patient was adequately mask ventilated with 100% oxygen. One minute later, blood pressure decreased to 51/26 mmHg associated with tachycardia (heart rate, 119 beats/min) and marked ST-segment depression on the ECG (lead Vs). The patient also developed a generalized erythema. He was immediately intubated. There were no signs of bronchospasm; the peak inspiratory pressures were normal. Intravenous epinephrine was administered at a dose of 200 pg, repeated 1 minute later, and followed by a continuous infusion at a rate of 0.2 pg/kg/min. The propofol infdsion was then stopped. In addition, hemodynamic stabilization required volume loading with crystalloids and the percutaneous placement of an intraaortic balloon pump. Isoflurane was gradually introduced with midazolam and a continuous infusion of morphine to replace the anesthetic drugs used during the induction. As the hemodynamics improved, epinephrine was progressively reduced and discontinued over 90 minutes. The surgical procedure was uneventful. Weaning hrn cardiopulmonary bypass was possible without inotropes. Extubation was performed 8 hours