Management of labor and delivery by spinal and epidural analgesia in a woman with systemic mastocytosis: a case report

Systemic mastocytosis is a life-threatening disease in which mast cell mediator release can lead to general symptoms. The most common triggers are stress and pain during labor and delivery. We report the management of labor and delivery in a case with severe systemic mastocytosis by epidural analgesia.

Adherence to recommended UK sampling protocols for detecting mast cell mediator release in perioperative anaphylaxis

BackgroundSheffield National Adverse Reactions Consultancy Service (NARCOS) investigates and triages suspected perioperative anaesthetic reactions to allergy clinics, using serial tryptase samples, urinary methylhistamine and clinical information on a pro forma request.ObjectiveTo determine if current UK guidelines on serial tryptase samples are achieved and describe the patterns of tryptase release.MethodA retrospective review of 3455 NARCOS cases. Tryptase and clinical details were analysed. 1746 had sufficient clinical information to grade the reactions according to the Ring and Messmer scale.Results98% provided two or more acute samples, but only 60% supplied clinical information. 308 patients never dropped within the reference range over three samples.ConclusionsGood compliance with UK guidelines for tryptase measurements is achievable in this long-term cohort, but obtaining clinical details at referral remains a challenge. Sample sequence labelling and apparent timing may be misleading. Baseline tryptase may frequently need to be rechecked in allergy clinics to estimate true peak-to-trough changes.

A Dog Is a Doctor’s Best Friend: The Use of a Service Dog as a Perioperative Assistant

Service dogs are beneficial in providing assistance to people with multiple types of disabilities and medical disorders including visual impairment, physical disabilities, seizure disorders, diabetes, and mental illness. Some service animals have been trained as a screening tool for cancer. We review a case involving a 6-year-old female with a history of mast cell mediator release and immediate hypersensitivity due to the urticaria pigmentosa variant of cutaneous mastocytosis who underwent a cystourethroscopy. Her service dog, JJ, who would alert to mast cell mediator release, was used throughout the perioperative course as a means of anxiolysis and comfort and to monitor for mast cell mediator release. This case presents an example of a service dog used in a family-care model in the field of anesthesiology and provides a unique example of using a service dog as an additional monitor to alert the care team for impending mast cell mediator release.

The occurrence of refractoriness and mast cell mediator release following mannitol-induced bronchoconstriction

For several hours after exercise-induced bronchoconstriction, there is diminished responsiveness to repeated challenge. The mechanism causing this refractoriness is unclear. Inhalation of dry powder mannitol is a new bronchial provocation test that has been suggested as a surrogate for an exercise challenge. Refractoriness to repeated mannitol challenge has however not been established. Our objective was to investigate if repeated challenge with mannitol is associated with refractoriness and diminished release of mast cell mediators of bronchoconstriction. Sixteen subjects with asthma underwent repeated inhalation of mannitol 90 min apart. Lung function was assessed by forced expiratory volume in 1 s (FEV1). The urinary excretion (ng/mmol creatinine) of the mediators 9α,11β-prostaglandin (PG) F2 and leukotriene (LT) E4 were measured. The group mean fall in FEV1 after the second challenge was 48.5 ± 5.8% of the first ( P < 0.001). The protection afforded by the initial challenge, however, varied considerably between subjects (range 88–0%). Furthermore, the urinary excretion of the two mediators was increased after both challenges. The average excretion of mediators after the challenges was significantly higher for the six most refractory subjects. This was observed both for LTE4 (95.6 ± 5.2 vs. 58.0 ± 2.4 for the 6 least refractory) ( P < 0.001) and for 9α,11β-PGF2 (137.6 ± 6.7 vs. 50.1 ± 1.1 for the 6 least refractory) ( P = 0.002). As occurs with exercise-induced bronchoconstriction, repeated inhalation of mannitol induced refractoriness. We propose that refractoriness is due to tachyphylaxis at the level of the airway smooth muscle responsiveness to mediators of bronchoconstriction rather than due to fatigue of their release from mast cells.