a 41-year - old patient visited the emergency center with a complaint of acute abdominal pain . the height of the patient was 175 cm , and his weight was 71 kg . he was diagnosed with acute gastric ulcer perforation , and underwent emergency surgery for laparoscopic repair . other than drinking one bottle of distilled liquor daily , the patient 's past medical history revealed no unusual findings . meperidine and nalbupine were injected in an intravenous loading dose , followed by intravenous administration of meperidine 200 mg mixed with a normal saline drip for the purpose of pain control during the patient 's entery into the operation room . after preoxygenation , the original anaesthetic consisted of thiopental and succinylcholine administered intravenously for induction . before administration of anaethesia , the patient 's vital signs included a blood pressure of 119/82 mmhg , regular sinus rhythm of pulse rate 91 beats / min , and peripheral oxygen saturation of 100% . fentanyl 1,000 g and ketorolac 180 mg in the saline solution were made by mixing 100 ml total , of which the loading dose of 10 ml and the remaining 90 ml prepared as a pca device ( accufuser plus 1008 m , wooyoung medical , korea ) and were mounted inside . following surgery of 1 hour 40 minutes duration , the loading dose of 9 ml of 10 ml ( fentanyl 90 g , ketorolac 16.2 mg ) for pca was administered intravenously for control of postoperative pain . pca was then connected to the intravenous line by 1 ml / hr basal continuous infusion . extubation was performed without complications , and the patient was transported to the postanesthetic care unit ( pacu ) . at that time , his vital signs included blood pressure of 122/83 mmhg , regular sinus rhythm of pulse rate 80 beats / min , and normal peripheral oxygen saturation . skin examination showed no unusual finding . therefore , chlorpheniramine 4 mg and dexamethasone 5 mg were administrated intravenously . after 10 minutes , wheals with erythematous rashes developed on the neck and upper limbs . therefore , chlorpheniramine 4 mg and hydrocortisone 100 mg were administrated intravenously . after 5 minutes , angioedema of the face was newly observed , with no relief from any symptoms ; both erythematous rashes and wheals spread over the entire body , including both extremities . at that time , body temperature indicated mild hyperthermia at 37.4. his vital signs showed low normal borderline blood pressure ; however , his pulse rate increased gradually , up to 120 beats per minute . findings from arterial blood gas analysis were ph 7.38 , pco2 41.6 mmhg , po2 55.9 mmhg , and oxygen saturation 89.1% . findings from examination with auscultation included wheezing , stridor on both lung fields , and a decreased breathing sound on both lower lung fields . further inquiry into the patient 's past medical history revealed hypersensitivity to ibuprofen , one of the nsaids in addition , aminophyline 250 mg and hydrocortisone 200 mg mixed in 100 ml normal saline respectively were administrated intravenously during intravenous fluid challenge . a full face mask ( mirage quattro , resmed , australia ) was applied with fio2 1.0 and continuous positive airway pressure ( cpap ) for improvement of oxygen saturation . therefore , the full face mask was replaced with a re - breathing oxygen mask ( medium concentration oxygen mask , telflex medical , usa ) as 5 l / minute oxygen . after an hour , his general condition showed significant improvement with reduced erythematous rashes and wheals ; however , he was transferred to the surgical intensive care unit due to the need for continuous monitoring . the next day , he was transferred to the general ward , and was discharged without further complications . the european academy of allergy and clinical immunology ( eaaci ) nomenclature committee proposed a broad definition of anaphylaxis as a severe , life - threatening , generalized or systemic hypersensitivity reaction . therefore minor , localized or non - systemic reactions , such as erythematous rashes or wheals are not included in the definition of anaphylaxis . clinical features of anaphylaxis may be identical ; however , anaphylaxis may be divided into allergic anaphylaxis and non - allergic anaphylaxis . allergic anaphylaxis is further subdivided into an immunoglobulin e mediated reaction and an immunological mechanism ( such as igg , complement activation ) mediated reaction , with the exception of ige . a general example of an ige mediated allergic anaphylaxis is an allergic reaction to peanut ingestion , and blood transfusion reactions are an example of an non - ige mediated allergic anaphylaxis . exact etiology for non - allergic anaphylaxis is unknown ; however , potential pathogenic mechanisms include idiosyncratic events , non - specific complementary activation , activation of humoral proteolytic systems , such as the clotting cascade , and direct histamine release . therefore , allergic anaphylaxis can be elucidated by skin test or drug - specific testing for ige ; however , non - allergic anaphylaxis can not be explained by testing for specific sensitivity . the more important point is that the one is often more severe with subsequent administration of the causal drug , but the other tends to be similar with repeat administration of the causal drug . clinical signs and symptoms can occur within seconds , but usually start within 5 - 10 minutes after intravenous administration of the responsible agent . estimated overall frequency between 1 in 3,500 and 1 in 25,000 has been reported in studies from france and australia . mortality from these reactions ranges from 3% to 6% , and an additional 2% of patients experience significant residual brain damage . because a number of drugs are administered simultaneously under anesthesia , these drugs can be implicated in allergic reactions , even if there is disparity between these drugs . major causal agents of anesthesia - related anaphylaxis include muscle relaxants ( 60% ) , latex ( 20% ) , antibiotics ( 15% ) , and colloids ( 4% ) , in that order . outside of that , anesthesia - related anaphylaxis rarely occurs with nsaids , opioids , and local anesthetics . even if nsaids rarely cause anesthesia - related anaphylaxis , nsaids induced anesthesia - related anaphylaxis has been reported in korea . mechanisms of nsaids induced anaphylaxis include inhibition of cyclo - oxygenase ( cox)-1 iso - enzyme with subsequent depletion of prostaglandin e2 , unstrained synthesis of cysteinyl leukotrienes ( cys - lt ) , and release of mediators from mast cells and eosinophils . therefore , anaphylaxis rarely occurs with weak cox-1 inhibitors , such as paracetamol and partial inhibitors of both cox-1 and cox-2 , such as nimesulide and meloxicam , and selective cox-2 inhibitors at usual drug doses ; it generally occurs only at high drug doses . currently , diagnosis of asa and nsaid - induced hypersensitivity reactions can only be established with provocative drug testing . as previously mentioned , because of non - ige mediated mechanisms , there are currently no available sige assays for asa or nsaid . the experimental diagnostic value of histamine and cys - lt release assays and flow - assisted quantification of in vitro activated basophils remains to be established . in this case , when the patient received preoperative intravenous administration of meperidine for control of pain , he did not develop symptoms or signs associated with meperidine . also , drugs administered between the period following surgery and pacu before anaphylaxis were drugs for pca and pyridostigmine and glycopyrrolate for reversal of neuromuscular blocker . through further inquiry into his past medical history , hypersensitivity to ibupropen and a hypersensitivity reaction were found to have occurred after injection of an intravenous loading dose for pca . hence , comprehensively , ketorolac was more suspicious than fentanyl as the pca 's that caused anaphylaxis . also , anaphylaxis occurred 30 minutes after injection of ketorolac , and the patient had experienced hypersensitivity reactions to other nsaids . therefore , in this case , anaphylaxis can be presumed anaphylactoid reaction as non - allergic anaphylaxis less than ige - mediated allergic anaphylaxis reaction definitely . when anaphylaxis is diagnosed , rapid management is critical . the major immediate treatments consist of epinephrine , oxygen 100% , intravenous fluid challenge , and intubation for airway maintenance . an initial dose of 50 g ( 0.5 ml , 1 : 10,000 solution ) intravenously or 300 - 500 g ( 0.3 - 0.5 ml , 1 : 1000 solution ) intramuscularly is recommended . in addition to having a beta - agonist , which is inotropic , and also a bronchodilator , it reduces further release of mediators , such as histamine and leukotrienes . intravenous injection of chlorpheniramine 10 mg as an anti - histamine agent and hydrocortisone 200 mg ( 0.25 - 1.0 g ) as a steroid are recommended . in case of severe bronchospasm , aminophylline , salbutamol , and magnesium sulphate can be given , and a beta-2 agonist may be inhaled using a metered - dose inhaler . hypotension leads to systemic vasodilation . therefore , 0.9% normal saline or lactated ringer 's solution are given rapidly , and the patient should be placed in the supine position . symptoms of dizziness and loss of consciousness can be induced by hypotension . at that time , the patient should be placed in the supine position , and venous return can be increased by elevation of both legs if necessary . in this case therefore , only anti - histamine and steroid were administered intravenously . when the hypersensitivity reaction became systemic , tachycardia and de - saturation developed . however , hypotension requiring adrenaline did not occur . to relieve bronchospasms , administration of aminophylline and establishment of cpap with full face mask were attempted . at that time , the patient was mentally alert and had no severe bronchospasm . hence , improvement of arterial oxygenation by use of a non - invasive full face mask , without intubation was attempted . application of a full face mask was effective for improvement of arterial oxygenation , even though he had a naso - gastric levin tube . a number of drugs are administrated simultaneously during the peri - operative period , and the patient can come in contact with causal agents directly through the site of the operation . therefore , in the event of anesthesia - related anaphylaxis , identification of the causes of anaphylaxis is difficult . hence , standardized methods for selection of high risk patients must be established through reported cases of anaphylaxis and close examination of the patient . in addition , we must be fully aware of differential diagnosis and appropriate treatment for anaphylaxis . in so doing , diagnosis and management of anaphylaxis must be rapid and exact .
anaphylaxis is a severe and life - threatening systemic hypersensitivity reaction . 
 ketorolac is a popular drug used for patient - controlled analgesia . 
 although anaphylactic reaction to ketorolac has not been frequently reported , it can develop by way of several mechanisms . 
 a 41-year - old male patient was scheduled for laparoscopic correction of a perforated gastric ulcer . 
 emergency surgery was performed under general anesthesia with no complications . near the end of anesthesia administration , 
 ketorolac in a loading dose was administered intravenously in order to launch patient - controlled analgesia . 
 following injection , urticaria - like skin lesions , including rashes and wheels appeared systemically ; tachycardia and breathing difficulty with oxygen desaturation also developed . through additional inquiry into the patient 's drug history , past experience with ibuprofen allergy was identified . 
 antihistamine , steroid , and aminophylline were administered , and continuous positive airway pressure by full facial mask was applied to relieve bronchospastic symptoms . 
 the patient recovered without further complications .