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symptom recurrence without re-exposure to the causative agent&#41; in the first 24&#8211;72&#160;hours&#44; which require hospital admission in severe cases&#44; must be considered&#46;</p></li></ul></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Vasovagal reaction</span><p id="par0045" class="elsevierStylePara elsevierViewall">This is the most frequent medical complication during dermatological surgery&#46; It has been reported in 1 in every 160 interventions&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Although its presentation may be alarming&#44; it usually has a benign&#44; self-resolving course&#46; However&#44; in very sensitive individuals it can cause cardiac arrest due to asystole&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">It is caused by a pathological response to various stimuli of the autonomic reflexes that control blood pressure and heart rate&#46; The Bezold-Jarisch reflex is activated&#44; causing an initial loss of sympathetic tone &#40;hypotension&#41; followed by intense vagal discharge &#40;bradycardia&#41;&#46; Either of the two components can predominate&#46; The resulting cerebral hypoperfusion can cause a temporary loss of consciousness &#40;syncope&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Although this type of reaction can occur in any individual in certain circumstances&#44; predisposing factors include individual susceptibility &#40;a history of vagal reactions to previous invasive procedures&#41;&#44; age less than 35 years&#44; female sex&#44; lack of sleep&#44; fasting&#44; ambient heat&#44; and standing&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In dermatological surgery&#44; triggers include fear&#44; the sight of blood and needles&#44; and pain&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Due to its neurogenic mechanism&#44; onset occurs rapidly &#40;within seconds&#41; and the episode duration can range from seconds to minutes&#46; With patient monitoring&#44; a drop in blood pressure and heart rate can be detected before the patient experiences symptoms&#44; which include feelings of weakness and dizziness&#44; paleness&#44; sweating&#44; and occasionally nausea and vomiting&#46; If the reaction proceeds loss of consciousness may occur&#44; followed by brief tonic&#8211;clonic contractions if the cerebral ischemia is very abrupt&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Preventive measures should be applied in young patients and&#47;or those with a history of reactions of this type&#46; Preventive measures and treatment&#44; to be applied after onset&#44; are listed in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Hyperventilation</span><p id="par0075" class="elsevierStylePara elsevierViewall">Acute hyperventilation syndrome is an abnormal response in certain individuals to a stressful event&#44; characterized by an increase in ventilation that exceeds metabolic demand&#46; It is more frequent in individuals with anxiety&#44; who&#44; in situations of fear&#44; breathe rapidly and shallowly using the upper part of the thorax&#46; This breathing pattern is often not apparent&#46; This leads to a decrease in the partial pressure of CO<span class="elsevierStyleInf">2</span> in the blood&#44; which is the main regulator of cerebral circulation&#44; giving rise to the cerebral vasoconstriction that underlies the clinical signs&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">It is characterized&#44; initially&#44; by a dysphoric presentation&#44; including anxiety&#44; lightheadedness&#44; shortness of breath and upset stomach&#44; nausea&#44; belching&#44; chest tightness&#44; perioral numbness&#44; acral paresthesia&#44; and even tetany of the hands&#46; Blood pressure and heart rate are initially normal&#44; but syncope can occur if the episode progresses&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Up until several years ago breathing into a paper bag was recommended in cases of hyperventilation with no organic cause&#46; However&#44; this technique is no longer considered effective&#46; Current treatment consists of guiding the patient&#8217;s breathing&#44; applying pressure with one hand on the upper chest&#44; and encouraging the patient to breathe more slowly using the diaphragm &#40;abdominal breathing&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of Interest</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
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          "identificador" => "xres1591555"
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          "titulo" => "Palabras clave"
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        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Anaphylaxis"
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        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Vasovagal reaction"
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        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Hyperventilation"
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        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Conflicts of Interest"
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        8 => array:2 [
          "identificador" => "xack562404"
          "titulo" => "Acknowledgments"
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        9 => array:1 [
          "titulo" => "References"
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    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2021-01-21"
    "fechaAceptado" => "2021-02-27"
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          "clase" => "keyword"
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          "identificador" => "xpalclavsec1430026"
          "palabras" => array:6 [
            0 => "Dermatologic surgery"
            1 => "Adverse events"
            2 => "Complications"
            3 => "Anaphylaxis"
            4 => "Vasovagal syncope"
            5 => "Hyperventilation"
          ]
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        0 => array:4 [
          "clase" => "keyword"
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          "palabras" => array:6 [
            0 => "Procedimientos quir&#250;rgicos dermatol&#243;gicos"
            1 => "Efectos adversos"
            2 => "Complicaciones"
            3 => "Anafilaxia"
            4 => "S&#237;ncope vasovagal"
            5 => "Hiperventilaci&#243;n"
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    "resumen" => array:2 [
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">This article&#44; part of a the series on safety in dermatologic procedures&#44; covers the diagnosis&#44; prevention&#44; management&#44; and treatment of 3 situations or conditions&#46; The first condition we address is anaphylaxis&#44; an uncommon but severe and potentially fatal reaction that must be recognized quickly so that urgent management coordinated with an anesthesiologist can commence&#46; The second is fainting due to a vasovagal reaction&#44; which is the most common complication in dermatologic surgery&#46; This event&#44; which occurs in 1 out of every 160 procedures&#44; usually follows a benign course and resolves on its own&#46; However&#44; in patients susceptible to vasovagal reactions&#44; syncope may lead to asystole and cardiac arrest&#46; The third is acute hyperventilation syndrome&#44; which is an anomalous anxiety-related increase in breathing rate beyond metabolic requirements&#46; Brief practical recommendations for managing all 3 events are included&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">En el presente art&#237;culo de la serie &#8220;Seguridad en procedimientos dermatol&#243;gicos&#8221; se aborda el diagn&#243;stico&#44; prevenci&#243;n&#44; manejo y tratamiento de tres situaciones&#46; Primeramente&#44; se aborda la anafilaxia&#58; una situaci&#243;n infrecuente&#44; grave y potencialmente mortal&#44; que requiere una identificaci&#243;n &#225;gil para un manejo urgente coordinado por parte de m&#233;dicos especialistas en Anestesiolog&#237;a&#46; En segundo lugar&#44; la reacci&#243;n vasovagal&#44; que es la complicaci&#243;n m&#233;dica m&#225;s frecuente durante la cirug&#237;a dermatol&#243;gica &#40;1 de cada 160 intervenciones&#41;&#44; con una evoluci&#243;n habitualmente benigna autorresolutiva&#44; pero que en individuos muy sensibles puede provocar una parada cardiaca por asistolia&#46; En tercer y &#250;ltimo lugar&#44; el s&#237;ndrome de hiperventilaci&#243;n aguda&#44; que es una respuesta an&#243;mala de determinados individuos a un evento estresante&#44; con un incremento de la ventilaci&#243;n que excede la demanda metab&#243;lica&#46; En los tres casos se incluyen recomendaciones que se plasman de forma pr&#225;ctica y somera&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">In memoriam&#46;</p>"
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      1 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Lobo-Valbuena B&#44; Martin-Gorgojo A&#44; Zafra-Cobo I&#44; S&#225;nchez-Estella J&#46; Seguridad en procedimientos dermatol&#243;gicos&#58; anafilaxia&#44; reacci&#243;n vasovagal e hiperventilaci&#243;n&#46; ACTAS Dermo-Sifiliogr&#46; 2021&#46; <span class="elsevierStyleInterRef" id="intr0005" href="https://doi.org/10.1016/j.ad.2021.02.010">https&#58;&#47;&#47;doi&#46;org&#47;10&#46;1016&#47;j&#46;ad&#46;2021&#46;02&#46;010</span></p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical manifestations of suspected anaphylaxis&#46;</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Adapted from Shaker et al&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Isometric counter-pressure maneuvers to prevent the progression of vasovagal reaction&#46; A&#44; Cross legs and engage leg muscles&#46; B&#44; Squeeze a rubber ball&#46; C&#44; Pull 2 hands in opposite directions&#46;</p>"
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          "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; MAP&#44; mean arterial pressure&#59; SpO<span class="elsevierStyleInf">2</span>&#44; oxygen saturation&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Immediate notification of the anesthesiology service if anaphylaxis is suspected</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n
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                  \t\t\t\t">Treatment</td><td class="td" title="\n
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                  \t\t\t\t">Description&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ABC &#40;life support&#41;</td><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">&#8226; Airway</span>&#58; ensure airway patency&#46;<span class="elsevierStyleItalic">&#8226; Breathing</span>&#58; ensure efficient breathing&#44; SpO<span class="elsevierStyleInf">2</span> &#62; 95&#37; &#40;provide oxygen therapy at &#62; 10 L&#47;min&#41;&#46;<span class="elsevierStyleItalic">&#8226; Circulation</span>&#58; ensure minimum perfusion pressure &#40;MAP&#160;&#62;&#160;65&#160;mmHg&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">First line&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Adrenaline &#40;as soon as possible&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">&#8226; Intramuscular &#40;better than subcutaneous&#41;&#58;</span>- Adults&#58; 0&#46;5&#160;mg &#40; approximately equivalent to 0&#46;01&#160;mg&#47;kg&#41;&#46;- Children&#58;&#60; 6 y&#44; 0&#46;15&#160;mg6&#8211;12 y&#44; 0&#46;3&#160;mg&#62;12 y&#44; 0&#46;5&#160;mgCan be repeated after 5&#8211;15&#160;minIntravenous&#58; 50&#8211;200&#160;&#181;g in bolus<span class="elsevierStyleItalic">Caution should be exercised to avoid overdose &#40;arrhythmia&#44; hypertensive crisis&#44; and pulmonary edema&#41;&#44; especially in patients with ischemic heart disease&#46;</span><span class="elsevierStyleItalic">Patients receiving chronic beta-blocker treatment have a poorer response&#46;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Fluid therapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">In the first 30&#160;min&#58;Adults&#58; 1&#8211;2 LChildren&#58; 20&#160;mL&#47;kg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Second line&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Corticosteroids&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">At the following doses for at least 3&#8211;4 days&#44; with subsequent progressive reduction&#58;Methylprednisolone&#44; 1&#160;mg&#47;kgHydrocortisone&#44; 200 mg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Antihistamines&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Dexchlorpheniramine&#44; 50 mg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Bronchodilators&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">In case of bronchospasm&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Referral to allergology &#40;if allergic reaction is suspected&#41;</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">To facilitate assessment&#44; it is recommended to determine plasma tryptase levels at 15&#160;min&#44; 3&#160;h&#44; and 24&#160;h&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Preoperative</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Frugal intake &#40;avoiding fasting&#41; and good hydration &#40;water intake&#41; beforehand&#44; surgical procedure permitting<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;8</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Preoperative oral anxiolytics &#40;in case of locoregional anesthesia&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Rapid-acting benzodiazepines 1&#160;h before&#58;Short half-life&#58; midazolam &#40;7&#46;5&#160;mg&#41;Long half-life&#58; diazepam &#40;5&#8211;10&#160;mg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">In highly susceptible individuals&#58;Atropine 0&#46;5&#160;mg &#40;intramuscular or subcutaneous&#41; 30&#160;min to 1&#160;h before surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Intraoperative</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Avoid excessive ambient heat in the operating theater&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Always perform painful or invasive techniques with the patient in a supine position&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Engage in conversation &#40;to distract&#44; without conveying anxiety or concern&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Keep needles&#44; blood&#44; etc&#46; out of patient&#8217;s line of sight&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">When starting the procedure in susceptible individuals or those with initial symptoms&#58;Perform isometric counter-pressure maneuver with force for 30&#160;s &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;<span class="elsevierStyleItalic">These maneuvers&#44; when properly executed&#44; greatly increase venous return and are effective in</span> 40&#37; <span class="elsevierStyleItalic">of individuals</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">In case of pain&#58; stop the procedure and re-anesthetize&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Treatment</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Initial maneuvers</span><a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Stop the stimuli that trigger the vagal reaction&#58;Stop surgical procedureRemove light from the patient&#8217;s face&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Trendelenburg position and&#47;or elevation of legs &#40;to increase venous return and cerebral perfusion&#41;&#44; turning head to one side for safety&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Promote ventilation and&#47;or administer oxygen via a mask&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Maneuvers that induce an adrenergic reaction&#58;Passing a cold wet compress over the faceInhalation of classic ammonium salts&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Pharmacotherapy</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">In cases of loss of consciousness and&#47;or persistent bradycardia &#60; 50 bpm&#58;</span>IV injection of 0&#46;5&#8211;1&#160;mg &#40;0&#46;5&#8211;1 ampoule&#41; of atropine sulfate&#46;The onset of atropine activity occurs approximately 2&#8211;4&#160;mL after IV injectionThe dose can be repeated every 3&#8211;5&#160;min&#44; up to a maximum of 3&#160;mg &#40;3 ampoules&#41;If the patient does not have a venous line or venous access is not possible&#44; other routes of administration can be used &#40;although the effect is delayed&#41;&#58; intramuscular &#40;5&#8211;30&#160;min&#41;&#44; subcutaneous &#40;15&#8211;30&#160;min&#41;&#44; and even sublingual &#40;not predictable&#44; but generally fast&#41;<span class="elsevierStyleItalic">Atropine is an essential drug in the emergency kit&#46; It is very safe and has no absolute contraindication in emergency situations&#46; Caution must be exercised in patients with ischemic heart disease and smooth fiber-mediated obstructive diseases&#46; It causes frequent but mild side effects &#40;blurred vision&#44; dry mouth&#44; palpitations&#44; etc&#46;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">In patients with persistent hypotension&#58;</span>Physiological serum&#58; 500&#160;mL in 5&#8211;10 min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Prevention and Treatment of Vasovagal Reaction<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;6&#8211;8</span></a></p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
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                          "etal" => true
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                    0 => array:2 [
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                      "Revista" => array:6 [
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                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
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            3 => array:3 [
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                            0 => "W&#46;J&#46; Wu"
                            1 => "L&#46;H&#46; Goldberg"
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                    0 => array:2 [
                      "doi" => "10.1097/DSS.0000000000001598"
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                          "etal" => false
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                    0 => array:1 [
                      "Revista" => array:2 [
                        "tituloSerie" => "Meds-cape&#46;"
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                      "WWW" => array:1 [
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                  ]
                ]
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            ]
            5 => array:3 [
              "identificador" => "bib0030"
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                            0 => "S&#46; Romano"
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                      ]
                    ]
                  ]
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                    0 => array:2 [
                      "doi" => "10.1007/s40292-019-00327-3"
                      "Revista" => array:6 [
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            6 => array:3 [
              "identificador" => "bib0035"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The use of moderate sedation for the secondary prevention of adverse vasovagal reactions"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "D&#46;J&#46; Kennedy"
                            1 => "B&#46; Schneider"
                            2 => "M&#46; Smuck"
                            3 => "C&#46;T&#46; Plastaras"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/pme.12632"
                      "Revista" => array:6 [
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                        "fecha" => "2015"
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            ]
            7 => array:3 [
              "identificador" => "bib0040"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Vasovagal reactions in blood donors&#58; risks&#44; prevention and management"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "A&#46; Thijsen"
                            1 => "B&#46; Masser"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Transfus Med&#46;"
                        "fecha" => "2019"
                        "volumen" => "29"
                        "paginaInicial" => "13"
                        "paginaFinal" => "22"
                      ]
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              ]
            ]
          ]
        ]
      ]
    ]
    "agradecimientos" => array:1 [
      0 => array:4 [
        "identificador" => "xack562404"
        "titulo" => "Acknowledgments"
        "texto" => "<p id="par0095" class="elsevierStylePara elsevierViewall">The authors thank all speakers and participants in the series of conferences on safety in dermatological procedures&#44; as well as all members of the Dermachat dermatological forum&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Several weeks after submitting this article Dr&#46; S&#225;nchez-Estella died of COVID-19&#46; He will be remembered with the deepest gratitude and admiration&#46;</p>"
        "vista" => "all"
      ]
    ]
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Journal Information
Vol. 112. Issue 8.
Pages 735-739 (September 2021)
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4297
Vol. 112. Issue 8.
Pages 735-739 (September 2021)
Review
Open Access
Safety in Dermatologic Procedures: Anaphylaxis, Vasovagal Reaction, and Hyperventilation
Seguridad en procedimientos dermatológicos: anafilaxia, reacción vasovagal e hiperventilación
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4297
B. Lobo-Valbuenaa, A. Martin-Gorgojob,
Corresponding author
alejandromartingorgojo@aedv.es

Corresponding author.
, I. Zafra-Coboc, J. Sánchez-Estellac,
a Servicio de Medicina Intensiva, Hospital Universitario del Henares, Coslada, Madrid, Spain
b Servicio ITS/Dermatología, Sección Especialidades Médicas, Organismo Autónomo Madrid Salud – Ayuntamiento de Madrid, Madrid, Spain
c Servicio de Dermatología, Complejo Asistencial de Zamora, Zamora, Spain
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Table 1. Treatment of Anaphylaxis
Table 2. Prevention and Treatment of Vasovagal Reaction4,6–8
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Abstract

This article, part of a the series on safety in dermatologic procedures, covers the diagnosis, prevention, management, and treatment of 3 situations or conditions. The first condition we address is anaphylaxis, an uncommon but severe and potentially fatal reaction that must be recognized quickly so that urgent management coordinated with an anesthesiologist can commence. The second is fainting due to a vasovagal reaction, which is the most common complication in dermatologic surgery. This event, which occurs in 1 out of every 160 procedures, usually follows a benign course and resolves on its own. However, in patients susceptible to vasovagal reactions, syncope may lead to asystole and cardiac arrest. The third is acute hyperventilation syndrome, which is an anomalous anxiety-related increase in breathing rate beyond metabolic requirements. Brief practical recommendations for managing all 3 events are included.

Keywords:
Dermatologic surgery
Adverse events
Complications
Anaphylaxis
Vasovagal syncope
Hyperventilation
Resumen

En el presente artículo de la serie “Seguridad en procedimientos dermatológicos” se aborda el diagnóstico, prevención, manejo y tratamiento de tres situaciones. Primeramente, se aborda la anafilaxia: una situación infrecuente, grave y potencialmente mortal, que requiere una identificación ágil para un manejo urgente coordinado por parte de médicos especialistas en Anestesiología. En segundo lugar, la reacción vasovagal, que es la complicación médica más frecuente durante la cirugía dermatológica (1 de cada 160 intervenciones), con una evolución habitualmente benigna autorresolutiva, pero que en individuos muy sensibles puede provocar una parada cardiaca por asistolia. En tercer y último lugar, el síndrome de hiperventilación aguda, que es una respuesta anómala de determinados individuos a un evento estresante, con un incremento de la ventilación que excede la demanda metabólica. En los tres casos se incluyen recomendaciones que se plasman de forma práctica y somera.

Palabras clave:
Procedimientos quirúrgicos dermatológicos
Efectos adversos
Complicaciones
Anafilaxia
Síncope vasovagal
Hiperventilación
Full Text
Anaphylaxis

Anaphylaxis is a severe, life-threatening situation, albeit rare. It can be caused by immunoglobulin E (IgE)-dependent or IgE-independent mechanisms. The characteristic clinical signs are presented in Figure 1.1 Recurrent skin and mucosal manifestations may or may not be observed, and clinical signs may be limited to arrhythmias, acute coronary syndrome, or severe asthma.

Figure 1.

Clinical manifestations of suspected anaphylaxis.

Adapted from Shaker et al.1

(0.66MB).
Figure 2.

Isometric counter-pressure maneuvers to prevent the progression of vasovagal reaction. A, Cross legs and engage leg muscles. B, Squeeze a rubber ball. C, Pull 2 hands in opposite directions.

(0.51MB).

Risk factors for poor outcome include chronic respiratory diseases, certain medications (β-blockers, angiotensin-converting enzyme inhibitors, nonsteroidal anti-inflammatory drugs, and benzodiazepines), a personal history of mastocytosis, and delayed adrenaline administration.1,2

Avoidance of triggers is essential for prevention. This means that the patient’s known allergies must be taken into account (e.g. latex allergies and possible cross-reactivity with foods such as kiwi, avocado, or banana).1,2

When considering treatment2 (Table 1) it is important to bear the following points in mind:

  • 1)

    The anesthesiology or intensive care services should be alerted as soon as anaphylaxis is suspected.

  • 2)

    Adrenaline should be administered early.

  • 3)

    The causative agent (e.g. antibiotics, blood products, contrast medium, latex) must be removed.

  • 4)

    The risk of biphasic responses (e.g. symptom recurrence without re-exposure to the causative agent) in the first 24–72 hours, which require hospital admission in severe cases, must be considered.

Table 1.

Treatment of Anaphylaxis

Immediate notification of the anesthesiology service if anaphylaxis is suspected
TreatmentDescription 
ABC (life support)• Airway: ensure airway patency.• Breathing: ensure efficient breathing, SpO2 > 95% (provide oxygen therapy at > 10 L/min).• Circulation: ensure minimum perfusion pressure (MAP > 65 mmHg). 
First line  Adrenaline (as soon as possible)  • Intramuscular (better than subcutaneous):- Adults: 0.5 mg ( approximately equivalent to 0.01 mg/kg).- Children:< 6 y, 0.15 mg6–12 y, 0.3 mg>12 y, 0.5 mgCan be repeated after 5–15 minIntravenous: 50–200 µg in bolusCaution should be exercised to avoid overdose (arrhythmia, hypertensive crisis, and pulmonary edema), especially in patients with ischemic heart disease.Patients receiving chronic beta-blocker treatment have a poorer response. 
  Fluid therapy  In the first 30 min:Adults: 1–2 LChildren: 20 mL/kg 
Second line  Corticosteroids  At the following doses for at least 3–4 days, with subsequent progressive reduction:Methylprednisolone, 1 mg/kgHydrocortisone, 200 mg 
  Antihistamines  Dexchlorpheniramine, 50 mg 
  Bronchodilators  In case of bronchospasm 
Referral to allergology (if allergic reaction is suspected)To facilitate assessment, it is recommended to determine plasma tryptase levels at 15 min, 3 h, and 24 h. 

Abbreviations: MAP, mean arterial pressure; SpO2, oxygen saturation.

Vasovagal reaction

This is the most frequent medical complication during dermatological surgery. It has been reported in 1 in every 160 interventions.3 Although its presentation may be alarming, it usually has a benign, self-resolving course. However, in very sensitive individuals it can cause cardiac arrest due to asystole.4

It is caused by a pathological response to various stimuli of the autonomic reflexes that control blood pressure and heart rate. The Bezold-Jarisch reflex is activated, causing an initial loss of sympathetic tone (hypotension) followed by intense vagal discharge (bradycardia). Either of the two components can predominate. The resulting cerebral hypoperfusion can cause a temporary loss of consciousness (syncope).

Although this type of reaction can occur in any individual in certain circumstances, predisposing factors include individual susceptibility (a history of vagal reactions to previous invasive procedures), age less than 35 years, female sex, lack of sleep, fasting, ambient heat, and standing.4

In dermatological surgery, triggers include fear, the sight of blood and needles, and pain.

Due to its neurogenic mechanism, onset occurs rapidly (within seconds) and the episode duration can range from seconds to minutes. With patient monitoring, a drop in blood pressure and heart rate can be detected before the patient experiences symptoms, which include feelings of weakness and dizziness, paleness, sweating, and occasionally nausea and vomiting. If the reaction proceeds loss of consciousness may occur, followed by brief tonic–clonic contractions if the cerebral ischemia is very abrupt.

Preventive measures should be applied in young patients and/or those with a history of reactions of this type. Preventive measures and treatment, to be applied after onset, are listed in Table 2.

Table 2.

Prevention and Treatment of Vasovagal Reaction4,6–8

Prevention   
Preoperative  Frugal intake (avoiding fasting) and good hydration (water intake) beforehand, surgical procedure permitting6,8 
  Preoperative oral anxiolytics (in case of locoregional anesthesia).7 Rapid-acting benzodiazepines 1 h before:Short half-life: midazolam (7.5 mg)Long half-life: diazepam (5–10 mg) 
  In highly susceptible individuals:Atropine 0.5 mg (intramuscular or subcutaneous) 30 min to 1 h before surgery 
Intraoperative  Avoid excessive ambient heat in the operating theater 
  Always perform painful or invasive techniques with the patient in a supine position 
  Engage in conversation (to distract, without conveying anxiety or concern) 
  Keep needles, blood, etc. out of patient’s line of sight 
  When starting the procedure in susceptible individuals or those with initial symptoms:Perform isometric counter-pressure maneuver with force for 30 s (Fig. 2)These maneuvers, when properly executed, greatly increase venous return and are effective in 40% of individuals 
  In case of pain: stop the procedure and re-anesthetize 
Treatment   
Initial maneuvers4  Stop the stimuli that trigger the vagal reaction:Stop surgical procedureRemove light from the patient’s face 
  Trendelenburg position and/or elevation of legs (to increase venous return and cerebral perfusion), turning head to one side for safety 
  Promote ventilation and/or administer oxygen via a mask 
  Maneuvers that induce an adrenergic reaction:Passing a cold wet compress over the faceInhalation of classic ammonium salts 
Pharmacotherapy  In cases of loss of consciousness and/or persistent bradycardia < 50 bpm:IV injection of 0.5–1 mg (0.5–1 ampoule) of atropine sulfate.The onset of atropine activity occurs approximately 2–4 mL after IV injectionThe dose can be repeated every 3–5 min, up to a maximum of 3 mg (3 ampoules)If the patient does not have a venous line or venous access is not possible, other routes of administration can be used (although the effect is delayed): intramuscular (5–30 min), subcutaneous (15–30 min), and even sublingual (not predictable, but generally fast)Atropine is an essential drug in the emergency kit. It is very safe and has no absolute contraindication in emergency situations. Caution must be exercised in patients with ischemic heart disease and smooth fiber-mediated obstructive diseases. It causes frequent but mild side effects (blurred vision, dry mouth, palpitations, etc.) 
  In patients with persistent hypotension:Physiological serum: 500 mL in 5–10 min 

Abbreviation: IV, intravenous.

Hyperventilation

Acute hyperventilation syndrome is an abnormal response in certain individuals to a stressful event, characterized by an increase in ventilation that exceeds metabolic demand. It is more frequent in individuals with anxiety, who, in situations of fear, breathe rapidly and shallowly using the upper part of the thorax. This breathing pattern is often not apparent. This leads to a decrease in the partial pressure of CO2 in the blood, which is the main regulator of cerebral circulation, giving rise to the cerebral vasoconstriction that underlies the clinical signs.

It is characterized, initially, by a dysphoric presentation, including anxiety, lightheadedness, shortness of breath and upset stomach, nausea, belching, chest tightness, perioral numbness, acral paresthesia, and even tetany of the hands. Blood pressure and heart rate are initially normal, but syncope can occur if the episode progresses.

Up until several years ago breathing into a paper bag was recommended in cases of hyperventilation with no organic cause. However, this technique is no longer considered effective. Current treatment consists of guiding the patient’s breathing, applying pressure with one hand on the upper chest, and encouraging the patient to breathe more slowly using the diaphragm (abdominal breathing).5

Conflicts of Interest

The authors declare that they have no conflicts of interest.

Acknowledgments

The authors thank all speakers and participants in the series of conferences on safety in dermatological procedures, as well as all members of the Dermachat dermatological forum.

Several weeks after submitting this article Dr. Sánchez-Estella died of COVID-19. He will be remembered with the deepest gratitude and admiration.

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Anaphylaxis-a 2020 practice parameter update, systematic review, and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) analysis.
J Allergy Clin Immunol., 145 (2020), pp. 1082-1123
[2]
Australasian Society of Clinical Immunology and Allergy. ASCIA Guidelines - Acute management of anaphylaxis. https://www.allergy.org.au/hp/papers/acute-management-of-anaphylaxis-guidelines.
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K. Minkis, A. Whittington, M. Alam.
Dermatologic surgery emergencies: Complications caused by occlusion and blood pressure.
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[5]
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Hyperventilation Syndrome.
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[8]
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In memoriam.

Please cite this article as: Lobo-Valbuena B, Martin-Gorgojo A, Zafra-Cobo I, Sánchez-Estella J. Seguridad en procedimientos dermatológicos: anafilaxia, reacción vasovagal e hiperventilación. ACTAS Dermo-Sifiliogr. 2021. https://doi.org/10.1016/j.ad.2021.02.010

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