Transient and sudden hypotension with use of fibrin glue!

undergoing spine surgery in prone position. It is likely that the hypersensitivity to fibrin glue resulted in sudden haemodynamic instability. Fibrin sealants (fibrin glue/fibrin adhesive) are the plasma‐derived products, which mimic the final stage of clotting pathway resulting in the conversion of fibrinogen to fibrin. These products have haemostatic properties and act independent of patients’ clotting mechanism in the body. These products are either homologous or autologous in origin.[1] They are used to achieve haemostasis to seal tissue and to support wound healing.[2] However, the use of these products is not free from complications. Severe and fatal incidents of anaphylactic reactions and thromboembolism have been reported in literature.[3-5] The incidence of hypersensitivity reactions is extremely rare, ranging from 0.5 per 100,000 cases for all reactions to 0.3 per 100,000 cases for serious reactions.[6] The serologic screening includes qualitative and quantitative estimation of aprotinin specific IgE and IgG antibodies.[7-9] Fibrin sealants contain human protein concentrate (fibrinogen, plasminogen and factor XIII), thrombin, aprotinin and calcium chloride. It is contraindicated in individuals with a known hypersensitivity to aprotinin. In few cases, these reactions have also progressed to severe anaphylaxis. [4-6] Such reactions are seen when fibrin sealants are applied repeatedly over time or in the same sitting. Koberand colleagues reported anaphylactic reaction due to systemic administration of aprotinin where it was used for coronary artery bypass graft surgery.[10] In another case, mortality was reported because of the application offibrin glue on adural tear.[11] Here, it is important to state that even if the first contactis well tolerated, it does not exclude the occurrence of an immediate or a delayed allergic reaction.[7,8] The signs and symptoms include bradycardia, tachycardia, hypotension, flushing, bronchospasm, wheezing, dyspnoea, nausea, urticaria, angioedema, pruritus, erythema and paraesthesia. Mild reactions can be managed with antihistaminic, steroids and adrenaline. The serologic screening includes qualitative and quantitative estimation of aprotinin‐specific IgE and IgG antibodies, skin prick tests for bovine aprotinin and drug-induced lymphocyte stimulation test.[7-9] However, in the postoperative period, we did not investigate our patient for antibodies specific for aprotinin, as the patient refused to give consent for further investigations. Incidence of embolism hasalso been reported with fibrin glue, hence it should not be injected directly into the circulatory system.[4] To avoid adverse life-threatening anaphylactic reactions, Transient and sudden hypotension with use of fibrin glue!