What are the management steps for a patient with erythema (redness) of the cheeks 12 hours post general anesthesia?

Management of Cheek Erythema 12 Hours Post-General Anesthesia

For isolated facial redness appearing 12 hours after general anesthesia without accompanying cardiovascular instability, bronchospasm, or angioedema, this presentation is most consistent with benign delayed flushing rather than anaphylaxis and requires only observation with documentation.

Clinical Assessment and Risk Stratification

The timing and isolated nature of this presentation are critical to management:

• Anaphylaxis during anesthesia typically manifests within minutes to one hour of drug exposure, not 12 hours later 1
• Delayed reactions (up to 1 hour) can occur with latex, antibiotics, IV colloids, and Cidex OPA, but 12 hours exceeds the expected timeframe 1
• Cutaneous signs occur in 72-94% of anaphylactic reactions, but they are accompanied by cardiovascular collapse (51%), hypotension (17%), or bronchospasm (40%) 1

Immediate Evaluation Required

Assess for features that would indicate true anaphylaxis:

• Vital signs: Check for hypotension, tachycardia, or bradycardia 1
• Respiratory status: Evaluate for bronchospasm, wheezing, or respiratory distress 1
• Skin examination: Look beyond the cheeks for widespread urticaria, angioedema (especially lips, tongue, airway), or generalized flushing 1
• Cardiovascular stability: Assess for signs of shock or cardiovascular collapse 1

Management Algorithm

If Isolated Facial Erythema Only (No Systemic Features)

This is the most likely scenario at 12 hours post-anesthesia:

• Observe the patient and document the finding 2
• No specific treatment is required for isolated flushing 2
• Flushing after anesthesia induction is common (6-32% depending on individual predisposition) and appears neurally mediated rather than allergic 2
• The patient can be reassured this is likely benign

If Any Systemic Features Present

Even at 12 hours, if cardiovascular or respiratory compromise develops, treat as anaphylaxis:

Immediate Management (ABC Approach)

• Call for help immediately 1
• Maintain airway and administer 100% oxygen 1
• Administer adrenaline IV: 50 mcg (0.5 mL of 1:10,000 solution) for adults, titrated to response 1
• Elevate legs if hypotensive 1
• Administer IV crystalloid (0.9% saline or lactated Ringer's) rapidly 1

Secondary Management

• Chlorphenamine 10 mg IV (adult dose) 1
• Hydrocortisone 200 mg IV (adult dose) 1
• Consider adrenaline infusion if multiple boluses required (1-4 mcg/min, maximum 10 mcg/min) 3

Diagnostic Workup

If Anaphylaxis is Suspected

Obtain mast cell tryptase levels even at 12 hours post-event 1:

• Collect 5-10 mL clotted blood samples
• A baseline tryptase should still be obtained (some individuals have elevated baseline levels) 1
• Document timing of sample collection relative to symptom onset 1

Follow-up Investigation

If true anaphylaxis occurred, refer for skin testing as soon as the patient has fully recovered 1:

• Skin testing can be performed once clinical recovery is complete and antihistamine effects have worn off 1
• Testing should include all anesthetic agents used: neuromuscular blocking agents, antibiotics, induction agents, latex, and chlorhexidine 1
• Intradermal testing may be more reliable for propofol 1
• Skin prick tests are most useful for latex, beta-lactam antibiotics, and neuromuscular blocking agents 1

Common Pitfalls to Avoid

• Do not assume isolated facial redness at 12 hours represents anaphylaxis without systemic features 1, 2
• Do not administer adrenaline for isolated flushing without cardiovascular or respiratory compromise, as IV adrenaline carries risk of lethal arrhythmias 3
• Do not dismiss the possibility of delayed anaphylaxis entirely—maintain vigilance for progression of symptoms 1
• If skin testing is planned, do not perform it within 3 weeks of a suspected reaction unless urgent surgery necessitates earlier testing, as early negative tests may be unreliable 4

Documentation Requirements

Record the following details for any suspected reaction 1:

• Exact timing of erythema onset relative to anesthesia induction and drug administration
• All anesthetic agents used and their timing
• Vital signs at time of symptom recognition
• Any treatment administered and patient response
• Copies of anesthetic record, recovery room chart, and drug charts