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Delayed pressure urticaria is a rare form of physical urticaria. After a pressure stimulus, erythematous painful wheals may develop after a delay of 1 to 12 hours. After manifestation these lesions may last for up to 72 hours. The case report presented here describes the successful intraoperative management of a 52-year-old woman experiencing this urticaria. This article discusses the preventive measures that were taken to avoid angioedema secondary to pressure related to anesthesia. Because of the rarity of the disease, anesthetic implications have not been addressed in the literature. Consideration of the symptoms and preoperative preventive measures may be of great benefit to all practitioners.
Keywords: Angioedema, chronic urticaria, delayed pressure urticaria.
Delayed pressure urticaria (DPU) is an uncommon form of chronic urticaria that manifests itself 1 to 12 hours after a pressure stimulus. Wheals commonly develop on the hands, feet, trunk, buttocks, legs, and face. Lesions due to DPU occur in the deep dermis layer, resulting in angioedema that may last for up to 72 hours. This angioedema is caused by the same pathogenic mechanisms as chronic urticaria; however, because of the depth of tissue involved, major manifestations occur.1 The DPU lesions are associated with flulike symptoms and arthralgia.2 All patients who experience DPU should avoid pressure on their skin. This form of urticaria is of particular interest to the anesthetist because the associated angioedema can manifest as laryngeal angioedema. The combination of the delayed onset and associated laryngeal edema could prove catastrophic for those with this disease.3
Case Summary
One week prior to an elective laparoscopic cholecystectomy, the surgeon consulted the anesthesia care team regarding an upcoming patient with DPU. After consultation with the anesthesia care team the operative schedule was manipulated to allow this 52-year-old woman to be the first case of the day. This decision was made to allow maximum anesthesia staff availability for follow-up assessment later in the afternoon. All postoperative healthcare providers were informed the peak manifestation of symptoms for DPU is 12 hours.
Preoperative anesthesia assessment revealed allergies to sulfonamides yielding hives and codeine causing angioedema. Medications included lisinopril, omeprazole, multivitamin, and prednisone as needed. Upon further questioning, the patient stated that she took 5 mg of prednisone "when she had flare-ups" of the urticaria. Prednisone,...