Department of Anesthesiology, Peking University Third Hospital, No. # 49, Huayuan Rd; Haidian Dist, Beijing, China.
BMC Anesthesiol. 2021 Jan 6;21(1):4. doi: 10.1186/s12871-020-01220-6.
Vancomycin (VCM) is effective in fighting Gram-positive bacteria related severe infections, and topical application of VCM powder is widely used in orthopedic surgery to prevent wound infection. However, VCM could lead to infusion rate-dependent antibody-and complement-independent anaphylaxis reaction by inducing direct release of histamine.
We retrospectively analyzed seven cases of severe hypotension and shock during wound closure or immediately after orthopedic surgery with unidentifiable reasons. We found that these cases were all associated with local application of VCM powder during wound closure process. Two patients experienced sudden cardiac arrest. Most of the cases (6/7) with circulatory collapse were discharged without severe sequelae. While one case with application of 3 g VCM developed cardiac arrest and remained in a coma due to hypoxic-hypoxic encephalopathy. The clinical presentations and the time of the shock onset were considered to be related with a VCM induced anaphylaxis reaction. However, as this was a retrospective study, and there was no laboratory examination performed, the conclusion was made upon differential diagnosis based on clinical manifestations and the timing of the shock.
Local application of VCM may not be as safe as was once believed and may lead to a related anaphylaxis. As VCM induced infusion-rate dependent, non-IgE mediated anaphylaxis is characterized by delayed occurrence, severe hypotension and even circulatory collapse, surgeons and anesthesiologists should be extra vigilant during and after VCM application.
万古霉素（VCM）在治疗革兰氏阳性菌相关的严重感染方面具有疗效，且局部应用 VCM 粉剂被广泛应用于骨科手术中以预防伤口感染。然而，VCM 可通过诱导组胺的直接释放，引起与输注速率相关的、抗体和补体非依赖性的过敏反应。
我们回顾性分析了 7 例在伤口闭合过程中或骨科手术后不久因不明原因出现严重低血压和休克的病例。我们发现这些病例均与伤口闭合过程中局部应用 VCM 粉剂有关。其中 2 例患者发生了心脏骤停。大多数（6/7）发生循环衰竭的病例在没有严重后遗症的情况下出院。而 1 例应用 3g VCM 的患者发生心脏骤停，并由于缺氧缺血性脑病而持续昏迷。休克的发作时间和临床表现被认为与 VCM 引起的过敏反应有关。然而，由于这是一项回顾性研究，且未进行实验室检查，因此该结论是基于临床表现和休克发生时间进行鉴别诊断得出的。
局部应用 VCM 可能不如以往认为的那样安全，并且可能导致过敏反应。由于 VCM 引起的输注速率依赖性、非 IgE 介导的过敏反应具有迟发性、严重低血压甚至循环衰竭的特点，外科医生和麻醉师在 VCM 应用期间和之后应格外警惕。
