Clinical Case For Discussion:    A 59-year-old male is undergoing a sigmoid  colectomy.  Twenty minutes  after surgery begins, the peak inspiratory pressure on the ventilator  rises to 50 cm H2O, and the systolic blood pressure reading on your vital signs monitor drops to 70.  What do you do?

Discussion:     You begin by rechecking the ABC’s of Airway, Breathing, and Circulation.   You suction the  endotracheal tube to be sure it is patent.  It is.  You squeeze the bag and listen to the lungs to make sure both lungs are ventilated.  They are, but there are diffuse wheezes.  You recheck the blood pressure device in the stat mode.  The repeat blood pressure is unchanged.  You feel for peripheral pulses, and they are not palpable.  Heart tones are present, but the rate is 140 beats per minute.  The oxygen saturation is 70%.  There are no acute ST changes on the ECG.  The exposed skin is normal.

You need a diagnosis to make the appropriate therapy.  This is the acute onset of a multi-system disorder, with bronchospasm and hypotension, in a previously healthy patient.  There are not many conditions that cause both acutely, and I want you to think of anaphylaxis early on.  A differential diagnosis includes:

(1)  an acute myocardial infarction, with left heart failure and pulmonary edema,

(2) acute septic shock, or

(3)  airway occlusion or acute asthma with decreased ventilation and cardiac dysfunction.  The absence of ST changes, arrhythmias, rales, or gallop make the first unlikely,  the second is very uncommon, and respiratory dysfunction is not likely to cause hypotension.

At the beginning of any surgery, multiple drugs including anesthetics, muscle relaxants, narcotics, and antibiotics are given in a short time period.  The identity of which drug is causing the allergic reaction is often impossible to determine.   Anaphylaxis secondary to latex exposure from  surgeon’s gloves has also been reported.

Regardless of the cause of the anaphylaxis, the treatment will be the same.

Anesthetic drugs are stopped, 100% oxygen is administered, and a bolus of intravenous fluid is given.   Treatment must include intravenous epinephrine.  Other causes of hypotension can be treated with  dopamine or phenylephrine, but anaphylaxis will not respond to these drugs.   Bronchospasm can be treated with  inhaled bronchodilators such as albuterol, but this  will have little effect in anaphylaxis.

Prompt epinephrine therapy is crucial.  The dose of epinephrine is important.  The 1 mg.  ampule of epinephrine needs to be diluted.  Treatment  is begun in 10 to 100 microgram increments,  and increased as needed.    The response should be immediate, with increase in systemic vascular resistance, blood pressure, and improvement in bronchospasm and oxygen saturation.  An epinephrine infusion may be needed to maintain vital signs.  An arterial line and central venous catheter are inserted.  Adjunct drugs such as steroids, diphenhydramine, and an H-2 blocker are given intraveously.

The surgery is quickly ended.  The patient is transferred to the ICU, with the trachea still intubated.   An excellent textbook reference on this topic is Benumof and Saidman, Anesthesia and Perioperative Complications, 1999, pp 409 – 420.

Anaphylaxis during general anesthesia can cause a fatal outcome even in ASA I and ASA II patients.  In 27 years of anesthesia, I have had 4 cases of anaphylaxis.  In these 4 episodes the offending drugs were    (1) protamine,  (2) intravenous contrast dye, (3) vecuronium, and (4) an unidentified drug.  The first time I witnessed this syndrome, it took me a long time to make the diagnosis.   I delayed the epinephrine therapy, and the patient had no response to phenylephrine, IV fluid boluses, and prayers  for her to get better.  In subsequent cases, early epinephrine therapy led to excellent outcomes.

If you were to ask graduating anesthesia residents what is likely to be the case of their career, most would probably say some big heart/thoracic/neuro/zebra type of case.  This case shows that it may be some typical case, where something bad happened when they were least expecting it.


Introducing …,  THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel. Publication date September 9, 2014 by Pegasus Books.

The first four chapters are available for free at Amazon. Read them and you’ll be hooked! To reach the Amazon webpage, click on the book cover image below:


Stanford professor Dr. Nico Antone leaves the wife he hates and the job he loves to return to Hibbing, Minnesota where he spent his childhood. He believes his son’s best chance to get accepted into a prestigious college is to graduate at the top of his class in this remote Midwestern town. His son becomes a small town hero and academic star, while Dr. Antone befriends Bobby Dylan, a deranged anesthetist who renamed and reinvented himself as a younger version of the iconic rock legend who grew up in Hibbing. An operating room death rocks their world, and Dr. Antone’s family and his relationship to Mr. Dylan are forever changed.

Equal parts legal thriller and medical thriller, The Doctor and Mr. Dylan examines the dark side of relationships between a doctor and his wife, a father and his son, and a man and his best friend. Set in a rural Northern Minnesota world reminiscent of the Coen brothers’ FargoThe Doctor and Mr. Dylan details scenes of family crises, operating room mishaps, and courtroom confrontation, and concludes in a final twist that will leave readers questioning what is of value in the world we live in.



Bang-Up Debut Novel, November 16, 2014

By Norm Goldman “Publisher & Editor of Bookpleasures”

This part legal and medical thriller is structured with a mixed bag of situations involving relationships, jealousy, evil, lies, courtroom drama, operating room mishaps as well as moments that engender conflicting and unexpected outcomes. Noteworthy is that as the suspense builds readers will become eager to uncover the truth involving a mishap concerning Nico and a surgical procedure that has unanticipated ramifications.

This is a bang-up debut from a writer who understands timing and is able to deliver hairpin turns, particularly involving the courtroom drama,that you would expect from a book of this genre.



allan mishra

This review is from: The Doctor and Mr. Dylan (Kindle Edition)

Just finished Dr. Novak’s delightful novel. I sincerely enjoyed his honest take about the pressures and values that exist within California’s Silicon Valley. He also brought the North Country of Minnesota to life with memorable characters and a twisting, addictive plot. Buried beneath the fun and funny story is a deeper message about how to best care for your kids, your relationships and yourself. Very well written and highly recommended.


By W. Brown

This review is from: The Doctor and Mr. Dylan (Kindle Edition)

I read this in hardcopy and loved it. A good well balanced novel. Characters and a story that I enjoyed and remember more than a month later. Got the book on a Saturday, and stayed up late on Monday to finish it. I rarely am so gripped by a book that I make the time to finish it that quickly.

It has some nice and unexpected plot twists, and an unusual mix of characters.

You’ll enjoy it.


Fun read. I could not put it down, November 18, 2014



This review is from: The Doctor and Mr. Dylan (Paperback)

Fun read. I could not put it down. Loved knowing a bay area doctor wrote this novel.

Five Stars, November 20, 2014


Kim (Portola Valley, CA USA)

This review is from: The Doctor and Mr. Dylan (Paperback)

Fun read, well written and highly recommend!

Learn more about Rick Novak’s fiction writing at

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  1. Thank you.
    This is the case I anticipate.
    I advise patients of risks, including the statement that if they were to have a severe allergic reaction, the best place would be in OT where there is oxygen, drugs, staff and experience.
    Thank you for sharing yours.

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