Delayed onset of life-threatening immune hemolysis after perioperative antimicrobial prophylaxis with cefotetan

• Published in: Canadian Journal of Surgery 2000-12, Vol.43 (6), p.461-462
• Main Authors: Ray, E K, Warkentin, T E, O'Hoski, P L, Gregor, P
• Format: Article
• Language: English
• Subjects: Anemia; Anemia, Hemolytic, Autoimmune - blood; Anemia, Hemolytic, Autoimmune - chemically induced; Anemia, Hemolytic, Autoimmune - therapy; Antibiotic Prophylaxis - adverse effects; Brief Communication; Causes; Cefotetan - adverse effects; Cephamycins - adverse effects; Cholecystectomy; Drugs; Erythrocyte Transfusion; Female; Hemoglobins - analysis; Herniorrhaphy; Humans; Immunology; Middle Aged; Physiological aspects; Time Factors
• ISSN: 0008-428X; 1488-2310

Cefotetan is a cephalosporin recommended for perioperative antimicrobial prophylaxis.1-3 A number of reports indicate that severe immunemediated hemolysis can occur during use of this drug.4-10 We report on a patient who presented with life-threatening hemolysis 7 days after receiving the last of 3 doses of antimicrobial prophylaxis with cefotetan given perioperatively for incisional hernia repair and incidental cholecystectomy. The delay between use of cefotetan, and subsequent cefotetan-induced immune hemolysis led to delayed recognition of the correct diagnosis. The consulting hematologist suspected a delayed-onset of immune hemolysis, perhaps from a perioperative medication. It was noted that 3 doses of cefotetan had been given perioperatively for prophylaxis (total, 3 g over 48 hours); 1 year earlier, she had received 9 doses of cefotetan without incident after surgery for a colocutaneous fistula. Although there had been an interval of 7 days between the last dose of cefotetan and the patient's presentation to the emergency department, cefotetan was investigated as a possible causative agent. None of the other drugs given (anesthetic agents: sufentanil, vecuronium bromide, propofol, neostigmine, glycopyrrolate; postoperative drugs: meperidine, morphine, dimenhydrinate, prochlorperazine, lorazepam, ranitidine) are known to cause immune hemolysis. From a serum drop in potassium from 4.0 to 3.0 mEq/L, the serum studies showed the effect of an uncomplicated potassium depletion on serum potassium to be a fall of 0.25 in mEq/L of serum potassium, representing a 25 to 50 mEq drop of deficit of total body potassium. Starting with normal serum potassium of 4, a drop of 1 mEq/L in serum potassium represents a potassium deficit of 100 to 200 mEq/L. A further drop from 3.0 to 2.5 represents a loss of 100 to 200 mEq/L for each drop of 0.25 mEq/L, or a 200 to 400 mEq deficit of potassium. Therefore, the total potassium deficit for a serum potassium = 2.5 = 100 to 200 plus 200 to 400 = 300 to 600 mEq of potassium deficit. 20[5] 21[i]