Case Report Volume 4 Issue 5- January 2018 DOI: 10.19080/JAICM.2018.04.555649 J Anest & Inten Care Med Copyright © All rights are reserved by Stefan Beckers Cardiac Bypass Surgery in a Patient with an Indolent Systemic Mastocytosis Stefan Beckers 1 *, Vincent Umbrain 1 , Carla Van Gompel 1 , Adriaan Sablon 1 , Elisabeth De Waele 2 , Christian Verborgh 1 , Jan Nijs 3 and Jan Poelaert 1 1 Department of Anesthesia and Perioperative Medicine, University Hospital Brussels, Belgium 2 Department of Intensive Care, University Hospital Brussels, Belgium 3 Department of Cardiac Surgery, University Hospital Brussels, Belgium Submission: December 15, 2017; Published: January 03, 2018 *Corresponding author: Stefan Beckers, Department of Anesthesia and Perioperative Medicine, University Hospital Brussels, Belgium, Email: J Anest & Inten Care Med 4(5): JAICM.MS.ID.555649 (2018) 001 Introduction Mastocytosis is a heterogeneous group of hematologic disorders with serious anesthetic implications. It is characterized by mast cell accumulation and proliferation in one or more organs, preferentially in the skin and in the bone marrow. Release of histamine and other mast cell mediators (tryptase, chymase, TNFα, IL 1, IL 6) can lead to cardiovascular collapse and even to death. We report successful perioperative management of a patient with a known indolent systemic mastocytosis, without any surgical antecedents scheduled for CABG (Cardiac Artery Bypass Grafting). Case Presentation A 57-year-old male with a medical history of 10 years of indolent systemic mastocytosis , presented for elective CABG. He had a history of arterial hypertension, obesity and smoking. Since 2 years, urticaria pigmentosa on his back augmented with many scratch lesions. A bone marrow biopsy was done, showing a D816V-mutation of the C-KIT proto-oncogen. There was no clear history or symptom of allergy. The serum tryptase level was fluctuating, but rising progressively over time. The level from last year was 76 microgram/l. In a general adult population, a median serum tryptase level is 5,1 microgram/l. Actual symptoms were thoracic pain, dyspnoea and diffuse pruritus over his body. His current medications included tritrace, aerius, cetirizine and lercanidipine hydrochloride. He denied a history to drug allergies or allergy to local anesthetic agents. Besides his arterial hypertension and obesity, he had also a familial predisposition for cardiovascular disease. Due to his mastocytosis, he was sent multidisciplinary to an allergist and to an anesthetist for a full examination. Before admission to the hospital, there was a multidisciplinary consultation between an anesthetist, an allergist, a cardiac surgeon and an intensive care physician. The patient was admitted to the hospital 24 hours preoperatively. He received prednisone 50mg and levocetirizine 10mg PO. Twelve hours preoperatively, he received prednisone 50mg PO, levocetirizine 10mg PO, ranitidine 150mg PO and montelukast 10 mg PO. Eight hours before surgical intervention, he was fasted. Two hours before intervention he received prednisone 50mg PO, levocetirizine 10mg PO, ranitidine 150mg PO, montelukast 10mg PO and lercadipine hydrochloride 10mg PO. One hour preoperatively, the patient received promethazine hydrochloride 50mg IM. Then surgery was performed in a latex- free environment per routine hospital practice. After installation and monitoring of ECG, pulse oximetry and noninvasive blood pressure, the patient received a peripheral venous catheter and a radial arterial catheter under local anesthesia. General anesthesia was induced with midazolam (3mg), propofol (250mg), sufentanil (20microgram) and cisatracurium (14mg) intravenously. Antibiotic prophylactic coverage was done with cefazoline 2g intravenously after endotracheal intubation. Maintenance was done with sevoflurane (2%ET) and with a continuous infusion of sufentanil keeping a NeuroSense (NeuroWave) from 40 to 60. Cerebral oximetry was also installed on the patient’s head to obtain NIRS. A deep central line was inserted in the right internal jugular vein without any problems. During the final installation for surgery and during the incision, the patient remained remarkably stable. The transoesophageal echocardiography examination after induction was quite normal showing no regional wall motion abnormabilities and borderline normal global left heart contractility. The patient remained hemodynamically stable, without erythema. Then he received heparine (4mg/ kg) intravenously before the start of the Extracorporeal Circulation. The surgeon performed two bypasses: left internal Keywords: Mastocytosis; Cardiac Bypass Surgery ; Cardiac Anesthesia ; Cardiovascular Collapse