Prolonged anaphylactic circulatory failure caused by blood transfusion during general anaesthesia

Blood transfusion is one of the causes of anaphylaxis during general anaesthesia. In most cases, adrenaline administration quickly alleviates circulatory failure and its continuous administration for days is very rare. We present the case of a 79-year-old man who experienced prolonged anaphylactic circulatory failure with increased histamine and tryptase concentrations following laparoscopic total gastrectomy, during which he received a blood transfusion. He developed hypotension soon after the initiation of blood transfusion during surgery. We immediately administered intravenous adrenaline, followed by a continuous adrenaline infusion to stabilise the circulation. Circulatory failure recurred and itchy wheals appeared when the adrenaline dose was reduced necessitating continuous adrenaline administration for > 24 h. The histamine and tryptase serum concentrations increased when the adrenaline dose was reduced. The timing of anaphylaxis onset and skin test results excluded rocuronium, cefazolin, ropivacaine and propofol as causes of the anaphylaxis. Therefore, the blood transfusion was the most likely cause. For anaphylaxis due to common causes, boluses of adrenaline often restore the circulation shortly after onset. However, transfusion-induced anaphylaxis, as in this case, can require prolonged infusion of adrenaline because of the lack of allergen clearance. For such cases, careful follow-up is very important.