Perioperative Anaphylaxis
"Perioperative anaphylaxis is a potentially life-threatening and
under-recognized event most commonly caused by antibiotics,
neuromuscular blocking agents, dyes, latex, and disinfectants. This
review provides updates in the epidemiology and pathogenesis of
perioperative anaphylaxis, discusses culprit agents, and highlights the
tenets of management including a comprehensive allergy evaluation."
Anaphylactic and anaphylactoid reactions during the perioperative period
"Anaphylactic reactions in the peri-operative period are often serious
and potentially life-threatening conditions, involving multiple organ
systems in which the clinical manifestations are the consequence of the
release of preformed mediators from mast cells and basophils.
Anaphylaxis is an immune mediated type I allergic reaction following the
massive release of mediators from mast cells and basophils as a
response to an allergen. Anaphylactoid reactions are defined as those
reactions that produce the same clinical picture with anaphylaxis but
are not IgE mediated, occur through a direct nonimmune-mediated release
of mediators from mast cells and/or basophils or result from direct
complement activation. The occurrence of these reactions during
anesthesia, although quite rare, remains a major concern for the
anesthesiologists."
Multiple drug allergies: Recommendations for perioperative management
"Life-threatening hypersensitivity reactions are more likely to occur in
patients with a history of allergy, atopy, or asthma. Hence, in a
patient who presented with a history of multiple drug allergies (MDA),
an allergological assessment should be performed prior to surgical
procedure. Drug allergies, being one of the causes of catastrophic
events occurring in the perioperative period, are of major concern to
anesthesiologists. Neuromuscular blocking agents are regularly used
during anesthesia and are one of the most common causes of perioperative
anaphylaxis. They are estimated to be responsible for 50%-70% of
perioperative hypersensitivity reactions. Antibiotics and latex
represent the next two groups of drug allergy. Allergic reactions to
propofol are rare with an incidence of 1:60,000 exposures. Although
intraoperative drug anaphylaxis is rare, it contributes to 4.3% of
deaths occurring during general anesthesia. These recommendations
discuss pathophysiology of MDA, preoperative evaluation, and anesthesia
considerations as well as the prevention and management of allergic
reactions in anesthetized patients with a history of MDA."
Perioperative approach of allergic patients
"Severe, generalized allergic reactions called anaphylaxis are estimated
to have a mortality of 3.5-4.8%. Adequate recognition and handling of a
severe perioperative anaphylactic reaction result in better outcomes,
including less hypoxic-ischemic encephalopathy and death. The diagnosis
of a perioperative allergic reaction can be difficult as the list of
possible culprits of a perioperative allergic reaction is extensive.
Making an informed guess on the causative agent and avoiding this agent
in future anesthesia procedures is undesirable and unsafe. Therefore, to
ensure future patient safety, a thorough investigation following a
perioperative allergic reaction is mandatory. A collaborate approach by
allergists and anesthesiologists is advised. In this article, we discuss
the basic approach of the allergic patient and of patients with a
suspected allergy to perioperatively administered medication."
Anaphylaxis During General Anaesthesia
"The incidence of anaphylaxis has been estimated at between 1 in 10 000
and 1 in 20 000 anaesthesias in Australia and 1 in 13 000 anaesthesias
in France. In the most recent French epidemiological survey, the
compounds most frequently involved in anaphylaxis were muscle relaxants
(60%), followed by latex (16%)."
"Activation of humoral and cellular pathways resulting from
immunoglobulin E-mediated adverse reactions usually produces
characteristic respiratory, cardiovascular and skin responses, but
effects can be seen in virtually any system. These responses may occur
as isolated clinical events. As a result, an anaphylactic reaction
restricted to a single clinical symptom (e.g. bronchospasm, tachycardia)
can easily be misdiagnosed. Intra- and postoperative investigations
must be performed to confirm the nature of the adverse reaction, the
role of the suspected drugs, and to define precise recommendations for
future anaesthesias. The patient must be fully informed, and given a
detailed written account of the anaphylactic episode, the results of the
allergological assessment performed and the resulting recommendations.
Furthermore, the patient should be strongly advise to wear a warning
bracelet or carry a warning card."
Allergic reactions during anesthesia at a large United States referral center
"Thirty-eight patients were found to have an anaphylactic reaction during
anesthesia, of which 18 were immunoglobulin (Ig)E-mediated anaphylactic
reactions (likely causative agent identified by skin test), 6 were
non-IgE-mediated anaphylactic reactions (elevated tryptase levels and
negative skin test), and 14 were probable non-IgE-mediated anaphylactic
reactions (tryptase levels normal or not obtained and negative skin
test). Of the IgE-mediated anaphylactic reactions, antibiotics were the
most prevalent likely causative agent (50%) whereas neuromuscular
blocking drugs were implicated as a likely causative agent in 11% of
reactions."
Practical guidelines for the response to perioperative anaphylaxis
"Muscle relaxants and antibiotics are the most common drugs that cause
perioperative anaphylaxis in Japan, as in many countries. In addition,
sugammadex appears to be a primary causative agent."
"Even if there are no skin symptoms, anaphylaxis should be suspected, especially when hypotension resistant to inotropes and vasopressors persists. For improving the diagnostic accuracy of anaphylaxis, it is helpful to collect blood samples to measure histamine/tryptase concentrations immediately after the events and at baseline. The first-line treatment for anaphylaxis is adrenaline. In the perioperative setting, adrenaline should be administered through the intravenous route, which has a faster effect onset and is secured in most cases. Adrenaline can cause serious complications including severe arrhythmias if the appropriate dose is not selected according to the severity of symptoms. The anesthesiologist should identify the causative agent after adverse events. The gold standard for identifying the causative agent is the skin test, but in vitro tests including specific IgE antibody measurements and basophil activation tests are also beneficial. The Working Group of the Japanese Society of Anesthesiologists has developed this practical guide to help appropriate prevention, early diagnosis and treatment, and postoperative diagnosis of anaphylaxis during anesthesia."
Anaphylaxis spares no drug: A report of diclofenac-induced anaphylaxis mimicking post-laparoscopy respiratory complication
"In the post-anesthesia care unit, the patient complained of respiratory
difficulty. Even after the supplemental oxygen and in absence of any
significant finding on respiratory examination, the patient soon
developed severe cardiorespiratory collapse. On evaluation,
administration of intravenous diclofenac a few minutes before the event
was suspected as the trigger for this anaphylactic response. The patient
responded to the injection of adrenaline, and her post-surgical
progress over the next two days was uneventful. The retrospective tests
done for confirming diclofenac hypersensitivity were found to be
positive. No drug, however safe, should be given blindly without proper
observation and monitoring. The course of development of anaphylaxis can
range from a few seconds to minutes and hence, the earliest recognition
and prompt action can be the only deciding factor between life and
death for such patients."
Intradermal skin testing in the investigation of suspected anaphylactic reactions during anaesthesia--a retrospective survey
"Sixty-five patients suffered a suspected anaphylactic reaction between
1976 and 2001. In 47 patients skin testing was performed and 43 of these
patients had positive skin tests: neuromuscular blockings drugs and
succinylcholine more specifically, were the most frequently incriminated
drugs. After the anaphylactic reaction 19 patients had surgery on 26
occasions with the use of a skin-test-negative neuromuscular blocking
drug; no problems occurred. Skin testing proved to be a reliable tool to
investigate suspected anaphylactic reactions during anaesthesia and to
guide the future use of neuromuscular blocking drugs."
Timing of skin testing after a suspected anaphylactic reaction during anaesthesia
"A delay of 4 to 6 weeks after a suspected anaphylactic reaction has
commonly been recommended before performing skin testing. However,
sometimes surgery cannot be delayed, and investigation must be done
earlier. Recent recommendations suggest that skin testing can be
performed immediately after a reaction."
"Review of the literature did not give a definite answer to the optimal timing of skin testing after a suspected anaphylactic reaction during anaesthesia."
"Only positive skin tests can be taken into account, and there is little safety data to provide confidence in early skin testing. A protocol of how to act if urgent surgery is necessary is suggested."
Suspected Anaphylactic Reactions Associated with Anaesthesia
CONTRAST MEDIA
Current Knowledge and Management of Hypersensitivity to Perioperative Drugs and Radiocontrast Media
"Several mechanisms are implicated, including IgE- and non-IgE-mediated
mechanisms. Perioperative anaphylaxis tends to be severe and has a
higher mortality rate than anaphylaxis in other settings. This is partly
due to factors that impair early recognition of anaphylaxis.
Neuromuscular blocking agents, latex containing products, and
antibiotics are the most common etiology. Chlorhexidine and dyes are
increasingly culprits. The newest emerging cause is sugammadex, which is
used for reversal of the effects of steroidal neuromusclar agents, such
as rocuronium. Latex-induced allergy is becoming less common than in
the 1980s due to primary and secondary prevention measures. Serum
tryptase levels during the time of anaphylaxis and skin testing to
suspected agents as an outpatient are necessary to confirm the
diagnosis. Management includes epinephrine and aggressive fluid therapy.
With radiocontrast media allergy, patients with a history of immediate
hypersensitivity reactions to radiocontrast media should receive steroid
and antihistamine premedication before re-exposure. Because
IgE-mediated anaphylaxis to radiocontrast media is rare, there is a
universal consensus that routinely skin testing all patients with a past
reaction is not effective."
Rapid collapse of the inferior vena cava in a patient with cardiac arrest induced by anaphylactic shock after iodinated contrast medium injection
"Anaphylactic shock to contrast media can progress to cardiac arrest
despite appropriate treatment. During anaphylactic shock to contrast
media, rapid vasodilation and a massive fluid shift can occur. Here we
report a patient who developed cardiac arrest induced by anaphylactic
shock to iodinated contrast medium and exhibited rapid collapse of the
inferior vena cava (IVC) on enhanced abdominal computed tomography (CT)
images. The patient underwent postsurgical unenhanced and
contrast-enhanced abdominal CT follow-up of cecum cancer. She had
neither allergy nor medical history except for the cancer. She did not
complain of any symptoms immediately after completion of the CT.
However, she developed anaphylactic shock and pulseless electrical
activity cardiac arrest only 2 minutes after finishing the CT despite
appropriate treatment. Emergency physicians successfully treated the
patient using advanced life support and targeted temperature management."
"The collapsed IVC is a good indicator of hypovolemia in patients with trauma. In this case, we considered that rapid vasodilation and a massive volume shift might have caused the collapsed IVC. This finding suggests the importance of aggressive volume resuscitation as well as epinephrine injection in patients with anaphylactic shock to contrast media. Furthermore, this finding occurred before the onset of clinical symptoms, and there is a possibility that it could be used as an indicator of anaphylactic shock to contrast media. "
A rapid caliber change in the inferior vena cava during multiphasic contrast-enhanced computed tomography may signal an acute anaphylactic reaction to nonionic contrast medium
"Severe anaphylactic reactions to an intravenous nonionic iodine contrast
medium (NICM) are uncommon but can result in permanent morbidity or
death if not managed appropriately. An anaphylactic reaction to an NICM
typically manifests as clinical symptoms that include an itchy nose,
sneezing, and skin redness. To our knowledge, a rapid change in the
caliber of the inferior vena cava (IVC) during multiphasic
contrast-enhanced computed tomography (CT) has not been reported. Here,
we report the computed tomographic findings in three cases of
hypovolemic shock caused by an anaphylactic reaction to an NICM. We
suspect that a decrease in caliber of the IVC during multiphasic
contrast-enhanced CT may be a predictor of an allergic-like reaction to
an NICM. Patients in whom physicians and radiographers detect a rapid
caliber change in the IVC during multiphasic contrast-enhanced CT should
be managed carefully.
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