The special anesthetic precautions needed in patients with systemic mastocytosis (SM) requiring surgery have been illustrated in a recently published case report in Annals of Cardiac Anesthesia.
CytoSorb is a recently developed cartridge system meant to retrieve inflammatory cytokines from the blood to decrease the risk of paraplegic syndrome. The study authors reported a case of a patient with SM requiring bypass cardiac surgery in which CytoSorb was successfully implemented.
AnaphylaxisAnaphylaxis A severe allergic reaction that can turn fatal without treatment. Patients with SM are at a higher risk of developing anaphylaxis. is a severe allergic reaction that can lead to death if untreated. It is characterized by a severe drop in blood pressure and airway obstruction due to bronchial spasm.
Mast cells are implicated in allergic reactions and anaphylaxis by releasing substances such as heparin, histamineHistamine A chemical released by mast cells when they are activated. Histamine causes many of the allergy-type symptoms in mastocytosis, including flushing, itching and hives., and prostaglandin that cause vasodilation and low blood pressure, as well as bronchial spasms that can compromise breathing.
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Therefore, patients with SM have an increased risk of anaphylaxis as they have increased mast cellMast cell A type of white blood cell produced in the bone marrow. They help defend against infections and play a key role in allergic reactions. In SM, mast cells become overactive and build up throughout the body. activity and proliferation. Many of the drugs used for general anesthesia, such as morphine and neuromuscular blocking agents, are potent stimulants for mast cell activationMast cell activation Describes when mast cells release histamine and other mediators into the blood stream in response to an allergen or other trigger. This leads to symptoms like fatigue, rash and, in severe cases, anaphylaxis.. Therefore, the anesthetic management of patients with SM is delicate.
“Protamine administration is another significant trigger for anaphylactic reaction. In SM, adverse reactions to protamine could be mediated by the release of inflammatory mediators, including histamine,” the authors wrote.
Despite the risks involved, protamine is the drug of choice to reverse the effects of heparin for on-pump cardiac surgery. Furthermore, cardiac surgery can induce the release of inflammatory substances called cytokines and cause a circulatory collapse known as vasoplegic syndrome.
The patient was 72 years old with a previous SM diagnosis. He presented with increasing difficulty breathing when performing mundane tasks, cardiologic examination revealed an aortic valve insufficiency that required surgical treatment.
The patient underwent standard surgical and anesthetic procedures with the addition of CytoSorb in the bypass system. The procedure was successful, and the patient did not experience vasoplegic syndrome or an anaphylactic reaction.
The authors remarked that further studies are required before affirming CystoSorb should be a regular part of anesthetic protocols for patients with SM.
“The interest and efficacy of CytoSorb to efficiently remove potential triggers in SM are not proven,” the authors wrote. ”Further studies are needed to evaluate the efficacy of CytoSorb in the particular case of SM.”
