Grade IV anaphylaxis unresponsive to code dose epinephrine in a healthy child presenting for mole removal under general anesthesia

Anaphylaxis during anesthesia is rare, especially in pediatric patients. Grade III and IV reactions are life threatening and early epinephrine administration is crucial. We present a case of grade IV anaphylaxis in a healthy child under general anesthesia for an elective surgery that was resistant to code dose epinephrine with infusion. Shortly after anesthesia induction, the patient developed tachycardia and severe hypotension that did not respond to initial escalating doses of epinephrine. To save the child from impending cardiac arrest, we had to administer in rapid succession multiple epinephrine boluses at amounts significantly higher than code dose. Although most anaphylaxis cases respond to 1 mcg/kg-10 mcg/kg epinephrine boluses and infusions, grade IV anaphylaxis can require astonishing amounts of epinephrine. Aggressive management with epinephrine in the face of little or no initial cardiovascular response is necessary in the most severe presentations of anaphylaxis.