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Koirala DP, Yadav M, Shah NA, Yadav D, Neupane S, Yadav C. Giant isolated splenic hydatid cyst in a pediatric patient: A rare case report. Int J Surg Case Rep 2024; 120:109768. [PMID: 38805842 PMCID: PMC11150960 DOI: 10.1016/j.ijscr.2024.109768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 05/10/2024] [Accepted: 05/14/2024] [Indexed: 05/30/2024] Open
Abstract
INTRODUCTION Hydatidosis, caused by Echinococcus granulosus, is endemic in regions where cattle rearing is prevalent. While liver and lung involvement are common, isolated splenic hydatid cysts are rare, particularly among adolescents. We present a rare case of a 14-year-old female with an isolated giant splenic hydatid cyst. CASE PRESENTATION A 14-year-old female presented with left upper quadrant pain. Imaging revealed a large splenic cyst without evidence of liver or lung involvement. A total splenectomy was performed, and a histological examination confirmed the diagnosis of a hydatid cyst. The patient underwent postoperative albendazole therapy and remained asymptomatic during follow-up. CLINICAL DISCUSSION Isolated splenic hydatid cysts are rare in the pediatric population. Imaging techniques such as ultrasound and CT play a crucial role in diagnosis. Surgical resection and Puncture-aspiration-injection-reaspiration remain the choice of treatment, supplemented by anti-parasitic therapy. Postoperative follow-up is essential to monitor for recurrence. CONCLUSION Isolated splenic hydatid cysts are exceptionally rare in pediatric patients. Prompt diagnosis, surgical intervention, and postoperative surveillance are crucial for successful management and prevention of recurrence.
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Affiliation(s)
| | - Manish Yadav
- Institute of Medicine, Tribhuvan University, Nepal.
| | | | - Digraj Yadav
- Institute of Medicine, Tribhuvan University, Nepal
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Zhang P, Wan Y, Li H, Lin X. Relationship between perioperative anaphylaxis and history of allergies or allergic diseases: A systematic review and meta-analysis with meta-regression. J Clin Anesth 2024; 94:111408. [PMID: 38387242 DOI: 10.1016/j.jclinane.2024.111408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 11/23/2023] [Accepted: 02/02/2024] [Indexed: 02/24/2024]
Abstract
STUDY OBJECTIVE We conducted this meta-analysis to summarize the available evidence and evaluate the relationship between a history of allergies/allergic diseases and perioperative anaphylaxis to offer preventive decision support. DESIGN Systematic review and meta-analysis of observational studies. SETTING We searched the MEDLINE (OVID), EMBASE, and the Cochrane Central Register of Controlled Trials databases for observational studies. Two investigators independently performed the search, screened the articles, and collected the study details. MEASUREMENTS Several databases were systematically searched to evaluate the relationship between a history of allergies/allergic diseases and perioperative anaphylaxis using subgroup analysis, sensitivity analysis and meta-regression. MAIN RESULTS A total of 19 studies involving 672 anaphylaxis episodes, 5608 immune-mediated reactions, and 1126 severe episodes met the eligibility criteria and were included in this meta-analysis. Drug allergies, food allergies, a history of allergies, and atopy increased the incidence of perioperative anaphylaxis (Drug allergies, odds ratio [OR] 3.54, 95% confidence interval [CI] 1.07-11.69; Food allergies, OR 2.29, 95% CI 1.23-4.26; A history of allergies, OR 4.86, 95% CI 3.65-6.49; Atopy, OR 3.58, 95% CI 1.47-8.71), but not the presence of immune-mediated reactions and the severity of perioperative anaphylaxis. CONCLUSIONS Patients with previous drug allergies, food allergies, a history of allergies, or atopy are more likely to develop anaphylaxis during the perioperative period. Additional studies should be carried out to determine whether a history of allergies/allergic diseases is a major factor for perioperative anaphylaxis when confounders are controlled.
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Affiliation(s)
- Panpan Zhang
- Department of Anesthesiology, West China Second University Hospital, Sichuan University, City of Chengdu, Sichuan 610041, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, China
| | - Yantong Wan
- Department of Anesthesiology, West China Second University Hospital, Sichuan University, City of Chengdu, Sichuan 610041, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, China
| | - Hao Li
- Department of Anesthesiology, West China Second University Hospital, Sichuan University, City of Chengdu, Sichuan 610041, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, China.
| | - Xuemei Lin
- Department of Anesthesiology, West China Second University Hospital, Sichuan University, City of Chengdu, Sichuan 610041, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, China.
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Winegarner A, Kendall MC, Stephen M, Siddiqui A. Delayed Anaphylactic Reaction to Midazolam in the Absence of Immediate Respiratory or Skin Manifestations. Case Rep Anesthesiol 2023; 2023:3873076. [PMID: 37767049 PMCID: PMC10522439 DOI: 10.1155/2023/3873076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 09/04/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
Anaphylaxis, a type 1 hypersensitivity reaction, is a feared but uncommon complication of medications administered in the perioperative period. The incidence of perioperative hypersensitivity reactions has been reported to range from 1 in 20,000 to 1 in 1,361. Anesthesiologists are well aware of common causes of hypersensitivity such as paralytics and antibiotics; however, less common triggers of anaphylaxis need to be considered as well. Midazolam, a short acting benzodiazepine metabolized by cytochrome P450 enzymes, is considered very safe with a minimal risk profile. Previous reports have described adverse reactions to occur within seconds to minutes following the administration of midazolam. We describe a patient with no known history of asthma or allergies who underwent elective hydrocelectomy with spinal analgesia without incident until 42 minutes later at the conclusion of the procedure, when they experienced circulatory collapse necessitating immediate emergency treatment. This case emphasizes the necessity to improve knowledge and awareness of delayed hypersensitivity reactions following the administration of perioperative medications such as midazolam.
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Affiliation(s)
- Andrew Winegarner
- Department of Anesthesiology, Rhode Island Hospital, Warren Alpert School of Medicine at Brown University, Providence 02903, RI, USA
| | - Mark C. Kendall
- Department of Anesthesiology, Rhode Island Hospital, Warren Alpert School of Medicine at Brown University, Providence 02903, RI, USA
| | - Mekhala Stephen
- Department of Interventional Pain Management and Anesthesia, Providence Veterans Affairs Medical Center, Providence 02903, RI, USA
| | - Afreen Siddiqui
- Department of Interventional Pain Management and Anesthesia, Providence Veterans Affairs Medical Center, Providence 02903, RI, USA
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Beukers AM, de Ruijter JAC, Loer SA, Vonk A, Bulte CSE. Effects of crystalloid and colloid priming strategies for cardiopulmonary bypass on colloid oncotic pressure and haemostasis: a meta-analysis. Interact Cardiovasc Thorac Surg 2022; 35:6581082. [PMID: 35512381 PMCID: PMC9419694 DOI: 10.1093/icvts/ivac127] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 04/11/2022] [Accepted: 05/02/2022] [Indexed: 11/14/2022] Open
Affiliation(s)
- Anne Maria Beukers
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Department of Anaesthesiology , Amsterdam, Netherlands
| | | | - Stephan Alexander Loer
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Department of Anaesthesiology , Amsterdam, Netherlands
| | - Alexander Vonk
- Amsterdam UMC Location University of Amsterdam, Department of Cardiothoracic Surgery , Amsterdam, Netherlands
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Weigel WA, Thilen SR. Neuromuscular Blockade Monitoring and Reversal: A Clinical and Pharmacoeconomic Update. Adv Anesth 2021; 39:169-188. [PMID: 34715973 DOI: 10.1016/j.aan.2021.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Wade A Weigel
- Department of Anesthesiology, Virginia Mason Franciscan Health, mailstop B2-AN, 1100 9th Avenue, Seattle, WA 98101, USA.
| | - Stephan R Thilen
- Anesthesiology & Pain Medicine, University of Washington, 325 Ninth Avenue, Seattle, WA 98104, USA
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Abstract
Perioperative anaphylaxis (PA) is a rare but life-threatening condition that poses diagnostic and management challenges in the operating room. The incidence of severe perioperative reactions is estimated to be approximately 1:7000-10,000. Management involves both immediate stabilization of the patient and identifying the culprit agent. Identification is essential to prevent recurrence of the event in subsequent surgeries and to avoid unnecessary labeling of drug allergy. Identifying all possible exposures including medications, disinfectants, latex, and dyes and choosing the appropriate tests are essential for proper evaluation. To identify the culprit, primary testing modalities include tryptase at the time of the reaction with subsequent levels and skin testing with nonirritating concentrations to the medications and substances utilized during the procedure and those potentially used as alternates. This strategy provides guidance for future surgeries and procedures. Close collaboration between the allergy, anesthesiology, and surgery teams is essential for appropriate management of these patients at the time of the reaction, during the post event evaluation and in preparation for subsequent surgeries.
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Che L, Li X, Zhang X, Zhang YL, Yi J, Ruan X, Ma S, Huang Y. The nature and reported incidence of suspected perioperative allergic reactions: A cross-sectional survey. J Clin Anesth 2021; 74:110404. [PMID: 34171710 DOI: 10.1016/j.jclinane.2021.110404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 06/07/2021] [Accepted: 06/10/2021] [Indexed: 10/21/2022]
Abstract
STUDY OBJECTIVE Perioperative allergic reactions (POHs) are common and can lead to severe intraoperative instability and even mortality. In contrast to the situation in developed countries, where databases of perioperative anaphylaxis are well documented and analyzed, relevant data are lacking in China. Therefore, we aimed to conduct a national survey to explore the characteristics of perioperative allergic reactions, as well as the knowledge and attitudes toward management and reporting among anesthesiologists. DESIGN Cross-sectional survey. SETTING Anesthesia department. PATIENTS A nationally representative sample comprising anesthesiologists from 12 province-level regions was selected. MEASUREMENTS A 20-item questionnaire was designed and validated using the Delphi method. Survey distribution was performed between June 2019 and January 2020 by the Chinese Society of Anesthesiology (CSA), which is the official academic society of Chinese anesthesiologists. Responses were compiled and analyzed. MAIN RESULTS We received responses from 4389 anesthesiologists across China. The estimated rate of suspected POH was 2/1000 patients (0.2%). On average, an anesthesiologist encountered 2.1 suspected POH cases per year. Neuromuscular blocking agents (NMBAs) were perceived as the most common causative agents, followed by antibiotics and succinylated gelatin. The rates of referral and allergy consultations were very low. Institutional support, including protocol development, cognitive aids, and tool kits, was not ideal. Additionally, the management of POH varied substantially. Most anesthesiologists believed that reporting and documenting POH was necessary. CONCLUSIONS Our survey revealed that POH is commonly encountered by Chinese anesthesiologists, but few patients are referred to allergy specialists or clinics for further investigation. A standardized recommendation based on research and data derived from Chinese patients is required.
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Affiliation(s)
- Lu Che
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing 100730, China
| | - Xu Li
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing 100730, China
| | - Xiuhua Zhang
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing 100730, China
| | - Yue Lun Zhang
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing 100730, China
| | - Jie Yi
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing 100730, China
| | - Xia Ruan
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing 100730, China
| | - Shuang Ma
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing 100730, China
| | - Yuguang Huang
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing 100730, China.
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A Suspected Anaphylactoid Reaction to Propofol in a Dog. Top Companion Anim Med 2021; 44:100536. [PMID: 33957306 DOI: 10.1016/j.tcam.2021.100536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 03/10/2021] [Accepted: 04/19/2021] [Indexed: 11/19/2022]
Abstract
Anaphylactoid reactions to anaesthetic drugs are rarely reported in veterinary medicine. The aim of this report is to describe a suspected anaphylactic reaction to propofol in a 14 years old Shih-Tzu undergoing general anaesthesia for ovariohysterectomy due to a pyometra. The anesthetic protocol included intramuscular methadone for premedication and fentanyl, midazolam and propofol intravenously for co-induction. At endotracheal intubation, the glottis appeared subjectively thickened. Shortly after induction and endotracheal intubation, desaturation, hypercapnia and bradycardia occurred; chest compliance at manual ventilation was poor and peripheral pulses were weak. The procedure was aborted. Pulmonary oedema was diagnosed at thoracic radiography and a cardiogenic origin was excluded via echocardiography. Fluid therapy and glucocorticoids were administered, and mechanical ventilation was started in the intensive care unit. Two hours later, the owner opted for euthanasia due to financial constraints.
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Critical Care Management of the Patient With Anaphylaxis: A Concise Definitive Review. Crit Care Med 2021; 49:838-857. [PMID: 33653974 DOI: 10.1097/ccm.0000000000004893] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Anaphylaxis is a rapidly progressive life-threatening syndrome manifesting as pruritus, urticaria, angioedema, bronchospasm and shock. The goal of this synthetic review is to provide a practical, updated approach to the evaluation and management of this disorder and associated complications. DATA SOURCES A MEDLINE search was conducted with the MeSH of anaphylaxis, anaphylactic reaction, anaphylactic shock, refractory anaphylaxis and subheadings of diagnosis, classification, epidemiology, complications and pharmacology. The level of evidence supporting an intervention was evaluated based on the availability of randomized studies, expert opinion, case studies, reviews, practice parameters and other databases (including Cochrane). STUDY SELECTION Selected publications describing anaphylaxis, clinical trials, diagnosis, mechanisms, risk factors and management were retrieved (reviews, guidelines, clinical trials, case series) and their bibliographies were also reviewed to identify relevant publications. DATA EXTRACTION Data from the relevant publications were reviewed, summarized and the information synthesized. DATA SYNTHESIS This is a synthetic review and the data obtained from a literature review was utilized to describe current trends in the diagnosis and management of the patient with anaphylaxis with a special emphasis on newer evolving concepts of anaphylaxis endotypes and phenotypes, management of refractory anaphylaxis in the ICU setting and review of therapeutic options for the elderly patient, or the complicated patient with severe cardiorespiratory complications. Most of the recommendations come from practice parameters, case studies or expert opinions, with a dearth of randomized trials to support specific interventions. CONCLUSION Anaphylaxis is a rapidly progressive life-threatening disorder. The critical care physician needs to be familiar with the diagnosis, differential diagnosis, evaluation, and management of anaphylaxis. Skilled intervention in ICUs may be required for the patient with complicated, severe, or refractory anaphylaxis.
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Romantowski J, Górska A, Niedoszytko M, Gulen T, Gruchała-Niedoszytko M, Nedoszytko B, Lange M, Brockow K, Arock M, Akin C, Valent P. A Challenge for Allergologist: Application of Allergy Diagnostic Methods in Mast Cell Disorders. Int J Mol Sci 2021; 22:1454. [PMID: 33535634 PMCID: PMC7867197 DOI: 10.3390/ijms22031454] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 01/27/2021] [Accepted: 01/28/2021] [Indexed: 12/12/2022] Open
Abstract
Primary and secondary mast cell activation syndromes (MCAS) can occur in patients with mastocytosis. During the past few years our knowledge about the pathogenesis and disease-triggering mechanisms in MCAS and mastocytosis have increased substantially. Whereas mastocytosis is characterized by an accumulation of neoplastic (clonal) mast cells (MC) in various organ systems, MCAS is defined by a massive and systemic activation of these cells. Mast cells are crucial effector cells in allergic diseases, thus their elevated number and activation can cause severe anaphylactic reactions and MCAS in patients with mastocytosis. However, these cells may also degranulate spontaneously or degranulate in response to non-allergic triggers leading to clinical symptoms. In mastocytosis patients, such symptoms may lead to the diagnosis of a primary MCAS. The diagnosis of a concomitant allergy in mastocytosis patients is challenging. In these patients, a mixed form (primary and secondary) of MCAS may be diagnosed. These patients may also suffer from life-threatening anaphylactic reactions when exposed to allergens. In these cases, the possibility of severe side effects of in vivo provocations can sometimes also limit diagnostic evaluations. In the current article, we discuss the diagnosis and management of patients suffering from mastocytosis and concomitant MCAS, with special emphasis on novel diagnostic tests and management, including allergen microarrays, recombinant allergen analysis, basophil activation tests, optimal prophylaxis, and specific therapies.
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Affiliation(s)
- Jan Romantowski
- Department of Allergology, Medical University of Gdansk, 80-211 Gdańsk, Poland; (A.G.); (M.N.)
| | - Aleksandra Górska
- Department of Allergology, Medical University of Gdansk, 80-211 Gdańsk, Poland; (A.G.); (M.N.)
| | - Marek Niedoszytko
- Department of Allergology, Medical University of Gdansk, 80-211 Gdańsk, Poland; (A.G.); (M.N.)
| | - Theo Gulen
- Department of Respiratory Medicine and Allergy, Karolinska University Hospital, 14186 Huddinge, Sweden;
- Immunology and Allergy Unit, Department of Medicine Solna, Karolinska Institutet, 17177 Stockholm, Sweden
| | | | - Bogusław Nedoszytko
- Department of Dermatology, Venerology and Allergology, Medical University of Gdansk, 80-211 Gdańsk, Poland; (B.N.); (M.L.)
| | - Magdalena Lange
- Department of Dermatology, Venerology and Allergology, Medical University of Gdansk, 80-211 Gdańsk, Poland; (B.N.); (M.L.)
| | - Knut Brockow
- Department of Dermatology and Allergy, School of Medicine, Technical University of Munich, D-80802 Munich, Germany;
| | - Michel Arock
- Department of Hematological Biology, Pitié-Salpêtrière Hospital, Pierre et Marie Curie University (UPMC), 75005 Paris, France;
| | - Cem Akin
- Division of Allergy and Clinical Immunology, University of Michigan, Ann Arbor, MI 48106, USA;
| | - Peter Valent
- Department of Internal Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, 1090 Vienna, Austria;
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, 1090 Vienna, Austria
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Hypersensitivity reaction to midazolam: a case of cardio-respiratory failure. Postepy Dermatol Alergol 2021; 37:1012-1013. [PMID: 33603624 PMCID: PMC7874856 DOI: 10.5114/ada.2020.102128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 07/07/2019] [Indexed: 11/17/2022] Open
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Cho CK, Change M, Lee SJ, Sung TY. Effects of neuromuscular blocking agents on the clinical performance of i-gel ® and surgical condition in elderly patients undergoing hand surgery: a prospective randomized controlled trial. Int J Med Sci 2021; 18:2381-2388. [PMID: 33967615 PMCID: PMC8100647 DOI: 10.7150/ijms.57489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 04/02/2021] [Indexed: 12/05/2022] Open
Abstract
Background: The effects of neuromuscular blocking agents on the clinical performance of supraglottic airway devices and surgical condition in elderly patients undergoing hand surgery have not been established. We evaluated the effects of rocuronium on the clinical performance of an i-gel® supraglottic device and surgical condition in elderly patients undergoing orthopedic hand surgery. Methods: Patients aged 65-85 years were randomized to receive either rocuronium (rocuronium group) or saline (control group). We compared the rates of successful insertion of the i-gel on the first attempt as a primary outcome and also assessed the adequacy of i-gel maintenance during controlled ventilation, anesthetic requirement, surgical condition, and recovery time. Results: The rates of successful insertion of the i-gel on a first attempt were 93.1% in the rocuronium group versus 82.1% in the control group (P = 0.423). Peak inspiratory pressure (PIP) was lower in the rocuronium group than in the control group (15.2 vs. 17.9 cmH2O, respectively, P = 0.028). Spontaneous breathing was less common in the rocuronium group (24.1% vs. 57.1%, respectively, P = 0.011). The requirement of additional fentanyl to suppress spontaneous breathing or patient movement was less in the rocuronium group than in the control group (24.1% vs. 50.0%, respectively, P = 0.043). Surgical condition did not differ between the two groups. Recovery time was shorter in the rocuronium group than in the control group (8.4 vs. 9.9 min, respectively, P = 0.030). Conclusions: Rocuronium did not enhance the success rate of inserting the i-gel® or the surgical condition in elderly patients. However, using rocuronium reduced PIP, the frequency of spontaneous breathing, the requirement for additional fentanyl and patients' recovery time.
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Affiliation(s)
- Choon-Kyu Cho
- Department of Anaesthesiology and Pain medicine, Konyang University Hospital, Myunggok Medical Research Center, Konyang University College of Medicine, Daejeon, Korea
| | - Minhye Change
- Department of Anaesthesiology and Pain medicine, Konyang University Hospital, Myunggok Medical Research Center, Konyang University College of Medicine, Daejeon, Korea
| | - Seok-Jin Lee
- Department of Anaesthesiology and Pain medicine, Konyang University Hospital, Myunggok Medical Research Center, Konyang University College of Medicine, Daejeon, Korea
| | - Tae-Yun Sung
- Department of Anaesthesiology and Pain medicine, Konyang University Hospital, Myunggok Medical Research Center, Konyang University College of Medicine, Daejeon, Korea
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Trenholme HN, Sakai DM, Berghaus LJ, Hanafi AL, Knych HK, Ryan CA, McHale B, Banovic F, Quandt JE, Barletta M, Reed RA. Effect of Meperidine on Equine Blood Histamine, Tryptase, and Immunoglobulin-E Concentrations. Front Vet Sci 2020; 7:584922. [PMID: 33426016 PMCID: PMC7786019 DOI: 10.3389/fvets.2020.584922] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 12/07/2020] [Indexed: 11/29/2022] Open
Abstract
Objectives: To evaluate changes in immunological parameters following subcutaneous (SC) and intramuscular (IM) administration of meperidine in horses through quantitative analysis of plasma tryptase, histamine, and IgE levels. Methods: Six adult horses were enrolled in a prospective randomized crossover design. Horses were administered one treatment per day, with a seven day washout period: (a) meperidine 1 mg/kg IM, saline 6 mL SC; (b) saline 6 mL IM, meperidine 1 mg/kg SC; (c) saline 6 mL SC, saline 6 mL IM. Blood samples were obtained for plasmatic histamine (baseline, 5, 10, 15, 30, and 60 min) via LC-MS/MS and plasmatic tryptase (baseline, 15, 30, 60, 120, and 240 min) quantification with enzyme-linked immunoabsorbent assays. Serum immunoglobulin E (IgE) concentrations prior to any meperidine treatment and 7–14 days following the first meperidine treatment were evaluated with enzyme-linked immunoabsorbent assays. Histamine and tryptase concentrations were evaluated with a mixed-effect analysis of variance. The levels of IgE at baseline (before the administration of the first dose of meperidine) were compared with the IgE values at 60 min following the second meperidine administration with the Paired t test. Biopsies of localized injection site reactions from subcutaneous meperidine administration were collected from two horses. Results: No statistically significant elevations from baseline in histamine (p = 0.595), tryptase (p = 0.836), or IgE (p = 0.844) were found in any of the horses in this study. There were no differences between treatment groups. Administration of SC meperidine caused a localized vasculitis and thrombosis with regional edema and hemorrhage. Conclusion: No evidence of anaphylactoid or anaphylactic type reactions occurred following IM or SC meperidine administration.
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Affiliation(s)
- H Nicole Trenholme
- Department of Large Animal Medicine, College of Veterinary Medicine, University of Georgia, Athens, GA, United States
| | - Daniel M Sakai
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, GA, United States
| | - Londa J Berghaus
- Department of Large Animal Medicine, College of Veterinary Medicine, University of Georgia, Athens, GA, United States
| | - Amanda L Hanafi
- Peterson and Smith Equine Hospital, Ocala, FL, United States
| | - Heather K Knych
- K.L. Maddy Equine Analytical Pharmacology Laboratory, School of Veterinary Medicine, University of California, Davis, Davis, CA, United States.,Department of Molecular Biosciences, School of Veterinary Medicine, University of California, Davis, Davis, CA, United States
| | - Clare A Ryan
- Department of Large Animal Medicine, College of Veterinary Medicine, University of Georgia, Athens, GA, United States
| | - Brittany McHale
- Infectious Disease Laboratory, College of Veterinary Medicine, Department of Small Animal Medicine and Surgery, University of Georgia, Athens, GA, United States
| | - Frane Banovic
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, GA, United States
| | - Jane E Quandt
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, GA, United States
| | - Michele Barletta
- Department of Large Animal Medicine, College of Veterinary Medicine, University of Georgia, Athens, GA, United States
| | - Rachel A Reed
- Department of Large Animal Medicine, College of Veterinary Medicine, University of Georgia, Athens, GA, United States
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Banerji A, Bhattacharya G, Huebner E, Fu X, Camargo CA, Guyer A, Kuhlen JL, Blumenthal KG. Perioperative Allergic Reactions: Allergy Assessment and Subsequent Anesthesia. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:1980-1991. [PMID: 33248280 DOI: 10.1016/j.jaip.2020.11.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 10/26/2020] [Accepted: 11/09/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Evidence-based guidelines are needed in the United States to improve evaluation of perioperative allergic reactions including recommendations for subsequent anesthesia. OBJECTIVE To identify causative agent(s) and evaluate patients' tolerability of subsequent anesthesia in patients evaluated by Allergy/Immunology (A/I) at Massachusetts General Hospital. METHODS We performed a retrospective review of patients referred to the outpatient A/I clinic for perioperative allergic reactions between October 2003 and May 2017. Patient demographics, atopic history, and prior adverse drug reactions were reviewed. Patients underwent a comprehensive evaluation with testing including skin testing (ST), drug challenges (when appropriate), tryptase level measurement, and specific IgE to latex measurement. Tolerance of subsequent procedures requiring anesthesia was assessed. RESULTS Of 123 patients referred, 74 (60%) were female and the mean age was 46 (±18) years. At least 1 causative agent was identified in 28 patients (24%, n = 28 of 118). Seventeen of 28 (61%) patients were ST positive to an antibiotic, including 13 (46%) positive to cefazolin; 3 patients (11%) had a positive latex specific IgE. Of 85 patients who had subsequent anesthesia with a known outcome, 78 (91%) did not have another perioperative allergic reaction. Two of 5 patients with an elevated baseline tryptase level did not tolerate subsequent anesthesia. CONCLUSION The majority of patients safely received subsequent anesthesia after comprehensive A/I evaluation for their perioperative allergic reactions; however, improved algorithmic care is needed in the United States. Among ST-positive patients (24%), antibiotics (especially cefazolin) were the most common culprits. An elevated baseline tryptase level was associated with an increased risk of recurrent perioperative allergic reactions.
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Affiliation(s)
- Aleena Banerji
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass.
| | - Gita Bhattacharya
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | - Emily Huebner
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | - Xiaoqing Fu
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | - Carlos A Camargo
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass; Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Mass
| | - Autumn Guyer
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California San Francisco, San Francisco, Calif
| | - James L Kuhlen
- Department of Medicine, Apex Allergy and Immunology, Greenville, SC
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass; Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital, Boston, Mass
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15
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Solé D, Spindola MAC, Aun MV, Araújo Azi LMTD, Bernd LAG, Garcia DB, Capelo AV, Cumino DDO, Lacerda AE, Lima LC, Morato EF, Nunes RR, Rubini NDPM, da Silva J, Tardelli MA, Watanabe AS, Curi EF, Sano F. [Update on perioperative hypersensitivity reactions: joint document from the Brazilian Society of Anesthesiology (SBA) and Brazilian Association of Allergy and Immunology (ASBAI) - Part II: etiology and diagnosis]. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2020; 70:642-661. [PMID: 33308829 PMCID: PMC9373683 DOI: 10.1016/j.bjan.2020.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 07/19/2020] [Accepted: 08/11/2020] [Indexed: 11/30/2022]
Abstract
This second joint document, written by experts from the Brazilian Association of Allergy and Immunology (ASBAI) and Brazilian Society of Anesthesiology (SBA) concerned with perioperative anaphylaxis, aims to review the pathophysiological reaction mechanisms, triggering agents (in adults and children), and the approach for diagnosis during and after an episode of anaphylaxis. As anaphylaxis assessment is extensive, the identification of medications, antiseptics and other substances used at each setting, the comprehensive data documentation, and the use of standardized nomenclature are key points for obtaining more consistent epidemiological information on perioperative anaphylaxis.
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Affiliation(s)
- Dirceu Solé
- Associação Brasileira de Alergia e Imunologia, São Paulo, SP, Brazil; Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo, SP, Brazil
| | - Maria Anita Costa Spindola
- Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brazil; Universidade Federal de Santa Catarina, Hospital Universitário Professor Polydoro Ernani de São Thiago, Florianópolis, SC, Brazil
| | - Marcelo Vivolo Aun
- Associação Brasileira de Alergia e Imunologia, São Paulo, SP, Brazil; Faculdade Israelita de Ciências da Saúde Albert Einstein, São Paulo, SP, Brazil; Universidade de São Paulo, Faculdade de Medicina, Hospital Universitário, São Paulo, SP, Brazil
| | - Liana Maria Tôrres de Araújo Azi
- Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brazil; Universidade Federal da Bahia, Hospital Universitário Professor Edgard Santos, Salvador, BA, Brasil.
| | - Luiz Antonio Guerra Bernd
- Associação Brasileira de Alergia e Imunologia, São Paulo, SP, Brazil; Fundação Faculdade Federal de Ciências Médicas de Porto Alegre, Porto Alegre, RS, Brazil
| | - Daniela Bianchi Garcia
- Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brazil; Hospital Infantil Pequeno Príncipe, Curitiba, PR, Brasil
| | - Albertina Varandas Capelo
- Associação Brasileira de Alergia e Imunologia, São Paulo, SP, Brazil; Universidade Federal do Rio de Janeiro, Hospital Universitário Gaffrée e Guinle, Rio de Janeiro, RJ, Brazil
| | - Débora de Oliveira Cumino
- Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brazil; Hospital Infantil Sabará, São Paulo, SP, Brazil
| | - Alex Eustáquio Lacerda
- Associação Brasileira de Alergia e Imunologia, São Paulo, SP, Brazil; Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo, SP, Brazil
| | - Luciana Cavalcanti Lima
- Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brazil; Instituto Medicina Integral Prrofessor Fernando Figueira, Recife, PE, Brazil
| | - Edelton Flávio Morato
- Universidade Federal de Santa Catarina, Hospital Universitário Professor Polydoro Ernani de São Thiago, Florianópolis, SC, Brazil
| | - Rogean Rodrigues Nunes
- Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brazil; Hospital Geral de Fortaleza (HGF), Departamento de Anestesia, Fortaleza, CE, Brazil
| | - Norma de Paula Motta Rubini
- Associação Brasileira de Alergia e Imunologia, São Paulo, SP, Brazil; Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Jane da Silva
- Associação Brasileira de Alergia e Imunologia, São Paulo, SP, Brazil; Universidade Federal de Santa Catarina, Hospital Universitário Professor Polydoro Ernani de São Thiago, Florianópolis, SC, Brazil
| | - Maria Angela Tardelli
- Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo, SP, Brazil; Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brazil
| | - Alexandra Sayuri Watanabe
- Associação Brasileira de Alergia e Imunologia, São Paulo, SP, Brazil; Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, São Paulo, SP, Brazil
| | - Erick Freitas Curi
- Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brazil; Universidade Federal do Espírito Santo, Vitória, ES, Brasil
| | - Flavio Sano
- Associação Brasileira de Alergia e Imunologia, São Paulo, SP, Brazil; Hospital Nipo Brasileiro, São Paulo, SP, Brasil
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Update on perioperative hypersensitivity reactions: joint document from the Brazilian Society of Anesthesiology (SBA) and Brazilian Association of Allergy and Immunology (ASBAI) - Part II: etiology and diagnosis. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2020. [PMID: 33308829 PMCID: PMC9373683 DOI: 10.1016/j.bjane.2020.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
This second joint document, written by experts from the Brazilian Association of Allergy and Immunology (ASBAI) and Brazilian Society of Anesthesiology (SBA) concerned with perioperative anaphylaxis, aims to review the pathophysiological reaction mechanisms, triggering agents (in adults and children), and the approach for diagnosis during and after an episode of anaphylaxis. As anaphylaxis assessment is extensive, the identification of medications, antiseptics and other substances used at each setting, the comprehensive data documentation, and the use of standardized nomenclature are key points for obtaining more consistent epidemiological information on perioperative anaphylaxis.
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17
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Ciobotaru OR, Stoleriu G, Ciobotaru OC, Grigorovici A, Voinescu DC, Matei MN, Cobzaru RG, Manolache N, Lupu MN. Postanesthetic skin erythema due to succinylcholine versus atracurium. Exp Ther Med 2020; 20:2368-2372. [PMID: 32765716 PMCID: PMC7401908 DOI: 10.3892/etm.2020.8792] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 04/14/2020] [Indexed: 12/28/2022] Open
Abstract
Intraoperative anaphylactic reactions may range from mild, erythema-like to anaphylactic shock, with tension crash and bronchospasm. The substances considered to be most responsible for the occurrence of intraoperative allergic reactions are neuromuscular blocking agents, antibiotics and latex. Recent studies have identified a new receptor, Mas-Related G-Protein-coupled Receptor X2 (MRGPRX2), considered as a target for some neuromuscular blockers such as atracurium, rocuronium or fluoroquinolone, resulting in pseudoallergic or anaphylactoid reactions. Induction of anesthesia can use both depolarizing myorelaxants, useful especially in emergency situations, in the patient with gastric plenitude or at high risk of intubation, and non-depolarizing myorelaxants such as atracurium, cisatracurium and rocuronium. Succinylcholine has a short time of action and it is rapidly metabolized. Atracurium, although having a slightly longer time to action, has the benefit of a low risk of increased levels of potassium in blood, which is extremely important in patients with cardiac pathology or associated kidney diseases. The present study compared the side effects of systemic anesthesia with succinylcholine vs. atracurium.
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Affiliation(s)
- Oana Roxana Ciobotaru
- Clinical Department, Faculty of Medicine and Pharmacy, ‘Dunărea de Jos’ University, 800008 Galati, Romania
| | - Gabriela Stoleriu
- Clinical Department, Faculty of Medicine and Pharmacy, ‘Dunărea de Jos’ University, 800008 Galati, Romania
| | - Octavian Catalin Ciobotaru
- Department of Surgery, Faculty of Medicine and Pharmacy, ‘Dunărea de Jos’ University, 800008 Galati, Romania
| | - Alexandru Grigorovici
- Department of Surgery, ‘Grigore T. Popa’ University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Doina Carina Voinescu
- Clinical Department, Faculty of Medicine and Pharmacy, ‘Dunărea de Jos’ University, 800008 Galati, Romania
| | - Madalina Nicoleta Matei
- Department of Dental Medicine, Faculty of Medicine and Pharmacy, ‘Dunărea de Jos’ University, 800008 Galati, Romania
| | - Roxana Gabriela Cobzaru
- Department of Preventive Medicine and Interdisciplinarity, Discipline Microbiology, ‘Grigore T. Popa’ University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Nicuta Manolache
- Department of Pharmaceutical Sciences, Faculty of Medicine and Pharmacy, ‘Dunărea de Jos’ University, 800008 Galati, Romania
| | - Mary-Nicoleta Lupu
- Department of Surgery, Faculty of Medicine and Pharmacy, ‘Dunărea de Jos’ University, 800008 Galati, Romania
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Linauskienė K, Grincevičienė G, Malinauskienė L, Blažienė A, Chomičienė A. Severe anaphylactic reaction to cisatracurium during anesthesia with cross-reactivity to atracurium. Open Med (Wars) 2020; 15:384-386. [PMID: 33313402 PMCID: PMC7706132 DOI: 10.1515/med-2020-0126] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 03/31/2020] [Accepted: 04/01/2020] [Indexed: 11/15/2022] Open
Abstract
A case of a severe anaphylactic reaction during general anesthesia was reported. Despite the high suspicion for cefuroxime as a trigger of the anaphylactic reaction, cisatracurium emerged being the culprit drug. This case illustrates the importance of testing all drugs used during procedures/operations, trying to find a culprit of anaphylaxis.
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Affiliation(s)
- Kotryna Linauskienė
- Vilnius University, Faculty of Medicine, Institute of Clinical, Medicine, Department of Chest diseases, Immunology and Allergology, Vilnius, Lithuania. Santariskiu 2, Vilnius LT-08661, Vilnius, Lithuania
| | - Gintarė Grincevičienė
- Outpatient department, Republican Panevezys Hospital Smėlynės g. 25, LT-35144, Panevėžys, Lithuania
| | - Laura Malinauskienė
- Vilnius University, Faculty of Medicine, Institute of Clinical Medicine, Department of Chest diseases, Immunology and Allergology, Vilnius, Lithuania. Santariskiu 2, Vilnius LT-08661, Vilnius, Lithuania
| | - Audra Blažienė
- Vilnius University, Faculty of Medicine, Institute of Clinical Medicine, Department of Chest diseases, Immunology and Allergology, Lithuania. Santariskiu 2, Vilnius LT-08661, Vilnius, Lithuania
| | - Anželika Chomičienė
- Vilnius University, Faculty of Medicine, Institute of Clinical Medicine, Department of Chest diseases, Immunology and Allergology, Vilnius, Lithuania. Santariskiu 2, Vilnius LT-08661, Vilnius, Lithuania
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Gonzalez-Diaz SN, de Lira-Quezada CE, Villarreal-Gonzalez RV, Guzman-Avilan RI, Macouzet-Sanchez C, Galindo-Rodriguez G. Perioperative Anaphylaxis. CURRENT TREATMENT OPTIONS IN ALLERGY 2020. [DOI: 10.1007/s40521-020-00250-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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20
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Poziomkowska-Gęsicka I, Kurek M. Clinical Manifestations and Causes of Anaphylaxis. Analysis of 382 Cases from the Anaphylaxis Registry in West Pomerania Province in Poland. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E2787. [PMID: 32316622 PMCID: PMC7215547 DOI: 10.3390/ijerph17082787] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 04/11/2020] [Accepted: 04/15/2020] [Indexed: 12/19/2022]
Abstract
Anaphylaxis is most commonly defined as an acute, severe, potentially life-threatening systemic hypersensitivity reaction. Current expert consensus has defined anaphylaxis as a serious reaction that is rapid in onset and can be fatal, and is a severe, potentially life-threatening systemic hypersensitivity reaction that is still rarely diagnosed. For safety reasons, patients should visit an allergologist to identify potential causes of this reaction. There are no data from other health care centres in Poland presenting characteristics of anaphylactic reactions. Clinical manifestations of anaphylaxis should be analysed, because some patients (10-30%) with anaphylaxis can present without cutaneous findings. This lack of skin/mucosa involvement can lead to misdiagnosis or delayed diagnosis of anaphylaxis. Objectives-to gather epidemiological data on anaphylactic reactions, to identify clinical manifestations of anaphylaxis (organ systems involved), to present diagnostic methods useful for the identification of anaphylaxis triggers, and most importantly, to find causes of anaphylaxis. In this retrospective analysis, we used a questionnaire-based survey regarding patients visiting the Clinical Allergology Department, Pomeranian Medical University (PMU) in Szczecin, between 2006 and 2015. The registry comprised patients with grade II (Ring and Messmer classification) or higher anaphylaxis. Patients with grade I anaphylaxis (e.g., urticaria) were not included in the registry. The incidence of anaphylaxis was higher in women. Clinical manifestations included cutaneous and cardiovascular symptoms, but more than 20% of patients did not present with cutaneous symptoms, which may create difficulties for fast and correct diagnosis. Causes of anaphylaxis were identified and confirmed by means of detailed medical interview, skin tests (STs), and measurement of specific immunoglobulin E (sIgE) and tryptase levels. In the analysed group, the most common cause of anaphylaxis (allergic and nonallergic) was Hymenoptera stinging (wasp), drugs (nonsteroidal anti-inflammatory drugs, NSAIDs) and foods (peanuts, tree nuts, celery). The incidence of anaphylaxis is low, but because of its nature and potentially life-threatening consequences it requires a detailed approach. Comprehensive management of patients who have had anaphylaxis can be complex, so partnerships between allergy specialists, emergency medicine and primary care providers are necessary. Monitoring its range is very important to monitor changes in allergy development.
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Affiliation(s)
- Iwona Poziomkowska-Gęsicka
- Clinical Allergology Department, Pomeranian Medical University (PMU) in Szczecin, Powstańców Wlkp 72, 70-111 Szczecin, Poland;
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21
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Daniel B, Wanner JP, Emerson B, Martus JE. Anaphylaxis secondary to albumin infusion during posterior spinal fusion for pediatric scoliosis. Spine Deform 2020; 8:327-331. [PMID: 32030641 DOI: 10.1007/s43390-020-00027-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Accepted: 07/28/2019] [Indexed: 10/25/2022]
Abstract
STUDY DESIGN Case report. OBJECTIVES To describe intraoperative administration of albumin as a cause of immunoglobulin E (IgE)-mediated anaphylaxis and cardiac arrest in an adolescent with adolescent idiopathic scoliosis. BACKGROUND Albumin is considered the reference intraoperative colloidal solution, and is used commonly as a volume expander for treating hypovolemia. Albumin rarely causes an anaphylactic reaction, with a documented rate of only 0.099%. METHOD An adolescent with scoliosis experienced acute, intraoperative hypotension during exposure for planned T5-L4 posterior spinal fusion shortly after infusion of albumin. She was treated rapidly and successfully with CPR and epinephrine. RESULTS Intraoperative transesophageal echocardiogram, chest radiograph, and serum histamine, serum tryptase, and urine N-methyl-histamine laboratory tests confirmed albumin anaphylaxis to be the etiology of the intraoperative event. Further postoperative complications were avoided as a result of the rapid diagnosis and treatment. CONCLUSIONS Although rare, IgE-mediated anaphylaxis to albumin, if administered, must be considered a possible cause of acute, intraoperative hypotension. Rapid management of anaphylaxis with communication between the surgeon, anesthesia team, and operative staff are essential if additional complications are to be avoided.
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Affiliation(s)
- Benjamin Daniel
- School of Medicine, Medical College of Georgia, 1120 15th St, Augusta, GA, 30912, USA
| | - J P Wanner
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, TN, 37232, USA
| | - Brian Emerson
- Division of Pediatric Anesthesiology, Vanderbilt Children's Hospital, 2200 Children's Way, Nashville, TN, 37232, USA
| | - Jeffrey E Martus
- Division of Pediatric Orthopaedics, Vanderbilt Children's Hospital, 2200 Children's Way, Nashville, TN, 37232, USA.
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Two Cardiac Arrests that Occurred after the Administration of Sugammadex: A Case of Kounis Syndrome. Case Rep Emerg Med 2020; 2020:6590101. [PMID: 32128264 PMCID: PMC7048914 DOI: 10.1155/2020/6590101] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 01/30/2020] [Indexed: 12/05/2022] Open
Abstract
Kounis syndrome is a form of acute coronary syndrome caused by allergic reactions. No cases of cardiac arrest caused by Kounis syndrome that arose after the administration of sugammadex have been reported. A 71-year-old female suffered two cardiac arrests. The first occurred after sugammadex was administered at the end of an operation for a right radial distal fracture. The patient was resuscitated and transferred to our intensive care unit. She was subsequently discharged home. Five months later, she suffered a second cardiac arrest after sugammadex was administered at the end of an operation for a right femoral neck fracture at our hospital. Urgent coronary angiography revealed multiple coronary spasms. Kounis syndrome was diagnosed based on the patient's elevated serum trypsin levels and a positive result in a skin allergy test of sugammadex. In cases of cardiac arrest with unclear etiologies, Kounis syndrome should be considered.
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23
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Risk factors and prevention for perioperative anaphylaxis: a nested case-control study. Int J Clin Pharm 2019; 41:1442-1450. [DOI: 10.1007/s11096-019-00902-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 09/05/2019] [Indexed: 02/07/2023]
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Integrating basophil activation tests into evaluation of perioperative anaphylaxis to neuromuscular blocking agents. Br J Anaesth 2019; 123:e135-e143. [DOI: 10.1016/j.bja.2019.02.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 02/07/2019] [Accepted: 02/24/2019] [Indexed: 01/11/2023] Open
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Jun JY, Kim YJ, Kim JH, Han JI. Hypersensitivity Reaction to Perioperative Drug Mistaken for Local Anesthetic Systemic Toxicity in a Patient under Brachial Plexus Block. KOSIN MEDICAL JOURNAL 2018. [DOI: 10.7180/kmj.2018.33.3.468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Perioperative anaphylaxis, although rare, is a severe, life-threatening unexpected systemic hypersensitivity reaction. Simultaneous administration of various drugs during anesthesia, the difficulty of communicate with patients in sedation and anesthesia, and coverage of the patient with surgical drapes are considered to be factors that impede early recognition of anaphylactic reactions. It is very important to perform an intradermal skin test because antibiotics are the most common cause of perioperative anaphylaxis. We report a case of negative-intradermal skin test antibiotic anaphylaxis mistaken for local aesthetic systemic toxicity without increase of serum tryptase for confirmative diagnostic biomaker during surgery under brachial plexus block. It is not possible to exclude the danger of anaphylaxis completely, even if it is negative-intradermal skin test and normal tryptase level. Therefore, anesthesiologists should be closely monitored and treated early for antibiotics related hypersensitive reaction, like other medicines during anesthesia.
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Porebski G, Kwiecien K, Pawica M, Kwitniewski M. Mas-Related G Protein-Coupled Receptor-X2 (MRGPRX2) in Drug Hypersensitivity Reactions. Front Immunol 2018; 9:3027. [PMID: 30619367 PMCID: PMC6306423 DOI: 10.3389/fimmu.2018.03027] [Citation(s) in RCA: 112] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 12/06/2018] [Indexed: 12/15/2022] Open
Abstract
The human ortholog MRGPRX2 and the mice ortholog, Mrgprb2 are activated by basic secretagogues and neurokinins. A number of commonly used small-molecule drugs (e.g., neuromuscular blocking agents, fluoroquinolones, vancomycin) have been recently shown to activate these receptors under in vitro experimental conditions, what results in mast cell degranulation. The above drugs are also known to cause IgE-mediated anaphylactic reactions in allergic patients. The new findings on mechanisms of drug-induced mast cell degranulation may modify the current management of drug hypersensitivity reactions. Clinical interpretation of mild drug-provoked hypersensitivity reactions, interpretation of skin test with a drug of interest or further recommendations for patients suspected of drug allergy are likely to be reconsidered. In the paper we discussed future directions in research on identification and differentiation of MRGPRX2-mediated and IgE-dependent mast cell degranulation in patients presenting clinical features of drug-induced hypersensitivity reactions.
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Affiliation(s)
- Grzegorz Porebski
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, Krakow, Poland
| | - Kamila Kwiecien
- Department of Immunology, Faculty of Biochemistry, Biophysics and Biotechnology, Jagiellonian University, Krakow, Poland
| | - Magdalena Pawica
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, Krakow, Poland
| | - Mateusz Kwitniewski
- Department of Immunology, Faculty of Biochemistry, Biophysics and Biotechnology, Jagiellonian University, Krakow, Poland
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Desai M, Castells M. Anaphylactic shock to bacitracin irrigation during breast implant surgery. Ann Allergy Asthma Immunol 2018; 122:217-218. [PMID: 30347235 DOI: 10.1016/j.anai.2018.10.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 10/08/2018] [Accepted: 10/10/2018] [Indexed: 12/28/2022]
Affiliation(s)
- Mauli Desai
- Department of Medicine, Division of Allergy & Clinical Immunology, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Mariana Castells
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Abstract
PURPOSE OF REVIEW The present review addresses the epidemiology, analyzes the current data and promotes global awareness of drug-induced anaphylaxis. RECENT FINDINGS Anaphylaxis is a medical emergency that may cause death! In the last decade, studies have shown an increasing incidence and prevalence of anaphylaxis. SUMMARY Drug-induced anaphylaxis fatalities have increased, and this syndrome remains underdiagnosed and undertreated.
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Di Leo E, Delle Donne P, Calogiuri GF, Macchia L, Nettis E. Focus on the agents most frequently responsible for perioperative anaphylaxis. Clin Mol Allergy 2018; 16:16. [PMID: 30002605 PMCID: PMC6038250 DOI: 10.1186/s12948-018-0094-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 06/23/2018] [Indexed: 11/27/2022] Open
Abstract
Adverse reactions (ARs) to drugs administered during general anesthesia may be very severe and life-threatening, with a mortality rate ranging from 3 to 9%. The adverse reactions to drugs may be IgE and non-IgE-mediated. Neuromuscular blocking agents (NMBA) represent the first cause of perioperative reactions during general anesthesia followed by latex, antibiotics, hypnotic agents, opioids, colloids, dyes and antiseptics (chlorhexidine). All these substances (i.e. NMBA, anesthetics, antibiotics, latex devices) may cause severe systemic non-IgE-mediated reactions or fatal anaphylactic events even in the absence of any evident risk factor in the patient's anamnesis. For this reason, in order to minimize perioperative anaphylactic reactions, it is important to have rapid, specific, sensitive in vitro diagnostic tests able to confirm the clinical diagnosis of acute anaphylaxis.
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Affiliation(s)
- E. Di Leo
- Unit of Internal Medicine, Section of Allergy and Clinical Immunology, “F. Miulli” Hospital, Acquaviva delle Fonti, BA Italy
| | - P. Delle Donne
- Department of Emergency and Organ Transplantation, School and Chair of Allergology and Clinical Immunology, University of Bari—Aldo Moro, Bari, Italy
| | - G. F. Calogiuri
- Pneumology Department, Sacro Cuore Hospital, Gallipoli, Lecce, Italy
| | - L. Macchia
- Department of Emergency and Organ Transplantation, School and Chair of Allergology and Clinical Immunology, University of Bari—Aldo Moro, Bari, Italy
| | - E. Nettis
- Department of Emergency and Organ Transplantation, School and Chair of Allergology and Clinical Immunology, University of Bari—Aldo Moro, Bari, Italy
- Policlinico, Piazza Giulio Cesare, 11, 70124 Bari, Italy
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30
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Maciag MC, Nargozian C, Broyles AD. Intraoperative anaphylaxis secondary to systemic cooling in a pediatric patient with cold-induced urticaria. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:1394-1395. [DOI: 10.1016/j.jaip.2018.03.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 03/16/2018] [Accepted: 03/22/2018] [Indexed: 10/17/2022]
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Mota I, Gaspar Â, Morais-Almeida M. Perioperative Anaphylaxis Including Kounis Syndrome due to Selective Cefazolin Allergy. Int Arch Allergy Immunol 2018; 177:269-273. [PMID: 29913447 DOI: 10.1159/000490182] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 05/14/2018] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Perioperative use of cefazolin has been associated with severe allergic reactions, and patients are usually labelled as allergic to penicillin afterwards. The aim of our study was to describe a group of patients with immediate reactions to cefazolin, with proven selective hypersensitivity reactions. METHODS Systematic review of all patients followed at our drug centre with cefazolin-related reactions, between January 2012 and December 2016. All patients were investigated according to the European Network for Drug Allergy (ENDA) recommendations through skin testing (major and minor penicillin determinants, penicillin, amoxicillin, cefazolin, cefuroxime and ceftriaxone) and oral challenges tests. RESULTS We included 7 patients (median age 40 years) with perioperative anaphylactic reactions immediately after cefazolin injection, 4 with hypotension and 1 with Kounis syndrome (KS) type I. The presence of a selective IgE-mediated hypersensitivity through positive skin tests to cefazoline has been proven in all patients. Two patients experienced systemic reactions during skin testing. All patients were successfully challenged with amoxicillin, and they tolerated cefuroxime. CONCLUSIONS Cefazolin can be responsible for immediate severe allergic reactions in perioperative setting, including KS. Allergological workup is essential for an accurate diagnosis and to explore cross-reactivity between cefazolin and other beta-lactams. Our experience confirmed that patients with IgE-mediated hypersensitivity reactions to cefazolin can tolerate other beta-lactams. This selective pattern of clinical reactivity may be explained by its particular chemical structure, whose R1 side-chain is different from other beta-lactams.
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Garro LS, Aun MV, Soares ISC, Ribeiro MR, Motta AA, Kalil J, Castells MC, Carmona MJC, Giavina-Bianchi P. Specific questionnaire detects a high incidence of intra-operative hypersensitivity reactions. Clinics (Sao Paulo) 2018; 73:e287. [PMID: 29791521 PMCID: PMC5938488 DOI: 10.6061/clinics/2018/e287] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 11/13/2017] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To assess the incidence of intra-operative immediate hypersensitivity reactions and anaphylaxis. METHODS A cross-sectional observational study was conducted at the Department of Anesthesiology, University of São Paulo School of Medicine, Hospital das Clínicas, São Paulo, Brazil, from January to December 2010. We developed a specific questionnaire to be completed by anesthesiologists. This tool included questions about hypersensitivity reactions during anesthesia and provided treatments. We included patients with clinical signs compatible with immediate hypersensitivity reactions. Hhypersensitivity reactions were categorized according to severity (grades I-V). American Society of Anesthesiologists physical status classification (ASA 1-6) was analyzed and associated with the severity of hypersensitivity reactions. RESULTS In 2010, 21,464 surgeries were performed under general anesthesia. Anesthesiologists answered questionnaires on 5,414 procedures (25.2%). Sixty cases of intra-operative hypersensitivity reactions were reported. The majority patients (45, 75%) had hypersensitivity reactions grade I reactions (incidence of 27.9:10,000). Fifteen patients (25%) had grade II, III or IV reactions (intra-operative anaphylaxis) (incidence of 7:10,000). No patients had grade V reactions. Thirty patients (50%) were classified as ASA 1. The frequency of cardiovascular shock was higher in patients classified as ASA 3 than in patients classified as ASA 1 or ASA 2. Epinephrine was administered in 20% of patients with grade III hypersensitivity reactions and in 50% of patients with grade II hypersensitivity reactions. CONCLUSIONS The majority of patients had hypersensitivity reactions grade I reactions; however, the incidence of intra-operative anaphylaxis was higher than that previously reported in the literature. Patients with ASA 3 had more severe anaphylaxis; however, the use of epinephrine was not prescribed in all of these cases. Allergists and anesthesiologists should implement preventive measures to reduce the occurrence of anaphylaxis.
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Affiliation(s)
- Laila S. Garro
- Divisao de Imunologia Clinica e Alergia, Faculdade de Medicina (FMUSP), Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Marcelo V. Aun
- Divisao de Imunologia Clinica e Alergia, Faculdade de Medicina (FMUSP), Universidade de Sao Paulo, Sao Paulo, SP, BR
- *Corresponding author. E-mail:
| | - Iracy Sílvia C. Soares
- Departamento de Anestesiologia, Faculdade de Medicina (FMUSP), Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Marisa R. Ribeiro
- Divisao de Imunologia Clinica e Alergia, Faculdade de Medicina (FMUSP), Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Antônio A. Motta
- Divisao de Imunologia Clinica e Alergia, Faculdade de Medicina (FMUSP), Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Jorge Kalil
- Divisao de Imunologia Clinica e Alergia, Faculdade de Medicina (FMUSP), Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Mariana C. Castells
- Division of Rheumatology, Immunology and Allergy, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Maria José C. Carmona
- Departamento de Anestesiologia, Faculdade de Medicina (FMUSP), Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Pedro Giavina-Bianchi
- Divisao de Imunologia Clinica e Alergia, Faculdade de Medicina (FMUSP), Universidade de Sao Paulo, Sao Paulo, SP, BR
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Burnett GW, Meisner J, Hyman JB, Levin EJ. Bacitracin irrigation leading to anaphylaxis and cardiovascular collapse in the ambulatory surgery center setting. J Clin Anesth 2018; 46:35-36. [DOI: 10.1016/j.jclinane.2018.01.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 12/22/2017] [Accepted: 01/04/2018] [Indexed: 10/18/2022]
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Intraoperative anaphylaxis to bacitracin during scleral buckle surgery. Ann Allergy Asthma Immunol 2017; 119:559-560. [PMID: 29042173 DOI: 10.1016/j.anai.2017.09.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 08/24/2017] [Accepted: 09/07/2017] [Indexed: 11/20/2022]
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Landsem LM, Ross FJ, Eisses MJ. A case of midazolam anaphylaxis during a pediatric patient's first anesthetic. J Clin Anesth 2017; 43:75-76. [PMID: 29049905 DOI: 10.1016/j.jclinane.2017.08.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 08/08/2017] [Accepted: 08/15/2017] [Indexed: 11/25/2022]
Affiliation(s)
- Leah M Landsem
- Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA, United States.
| | - Faith J Ross
- Anesthesiology and Pain Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, United States
| | - Michael J Eisses
- Anesthesiology and Pain Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, United States
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Iammatteo M, Keskin T, Jerschow E. Evaluation of periprocedural hypersensitivity reactions. Ann Allergy Asthma Immunol 2017; 119:349-355.e2. [DOI: 10.1016/j.anai.2017.07.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 07/08/2017] [Accepted: 07/11/2017] [Indexed: 12/18/2022]
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Abstract
Drugs are among the main triggers of anaphylaxis, but identification of the culprit drug is frequently difficult. To confirm diagnosis of the causative agent, medical records and clinical history are fundamental. There are a few in vitro tests available in clinical practice, such as serum-specific IgE and basophil activation test. Skin tests are often useful for the diagnosis, although drug challenge is indicated in patients with inconclusive clinical history or to provide safe alternatives. Treatment of anaphylaxis is standard and intramuscular epinephrine is the main agent to prevent morbidity and mortality. Rapid desensitization may be indicated in selected cases.
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Affiliation(s)
- Marcelo Vivolo Aun
- Avenida Eneas de Carvalho Aguiar 155, 8th Floor, Prédio dos Ambulatórios, Bloco 03, 05403-900, Sao Paulo, Brasil.
| | - Jorge Kalil
- Avenida Eneas de Carvalho Aguiar 155, 8th Floor, Prédio dos Ambulatórios, Bloco 03, 05403-900, Sao Paulo, Brasil
| | - Pedro Giavina-Bianchi
- Avenida Eneas de Carvalho Aguiar 155, 8th Floor, Prédio dos Ambulatórios, Bloco 03, 05403-900, Sao Paulo, Brasil
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Haybarger E, Young AS, Giovannitti JA. Benzodiazepine Allergy With Anesthesia Administration: A Review of Current Literature. Anesth Prog 2017; 63:160-7. [PMID: 27585420 PMCID: PMC5011959 DOI: 10.2344/16-00019.1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 06/06/2016] [Indexed: 12/19/2022] Open
Abstract
The incidence of anaphylactic/anaphylactoid reactions has been reported to vary between 1 : 3500 and 1 : 20,000 cases with a mortality rate ranging from 3 to 9%. Clinical signs present as skin rash, urticaria, angioedema, bronchospasm, tachycardia, bradycardia, and hypotension. Rapid identification and treatment are crucial to overall patient prognosis, as delayed intervention is associated with increased mortality. Diagnosis may be confirmed with clinical presentation, serum tryptase levels, and skin test results. While the main causative agents in anesthetic practice are typically neuromuscular blocking agents (NMBs), latex, and antibiotics, this review aims to discuss recognition, management, and preventive measures in perioperative anaphylactic/anaphylactoid reactions from benzodiazepine administration.
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Affiliation(s)
- Elliot Haybarger
- Dentist Anesthesiologist, Greenville, South Carolina. Former Resident in Dental Anesthesiology, University of Pittsburgh, Pennsylvania
| | - Andrew S. Young
- Resident in Dental Anesthesiology, University of Pittsburgh, Pennsylvania
| | - Joseph A. Giovannitti
- Professor and Chair, Department of Dental Anesthesiology, University of Pittsburgh, Pennsylvania
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Reclassifying Anaphylaxis to Neuromuscular Blocking Agents Based on the Presumed Patho-Mechanism: IgE-Mediated, Pharmacological Adverse Reaction or "Innate Hypersensitivity"? Int J Mol Sci 2017; 18:ijms18061223. [PMID: 28590439 PMCID: PMC5486046 DOI: 10.3390/ijms18061223] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 06/01/2017] [Accepted: 06/02/2017] [Indexed: 01/18/2023] Open
Abstract
Approximately 60% of perioperative anaphylactic reactions are thought to be immunoglobulin IgE mediated, whereas 40% are thought to be non-IgE mediated hypersensitivity reactions (both considered non-dose-related type B adverse drug reactions). In both cases, symptoms are elicited by mast cell degranulation. Also, pharmacological reactions to drugs (type A, dose-related) may sometimes mimic symptoms triggered by mast cell degranulation. In case of hypotension, bronchospasm, or urticarial rash due to mast cell degranulation, identification of the responsible mechanism is complicated. However, determination of the type of the underlying adverse drug reaction is of paramount interest for the decision of whether the culprit drug may be re-administered. Neuromuscular blocking agents (NMBA) are among the most frequent cause of perioperative anaphylaxis. Recently, it has been shown that NMBA may activate mast cells independently from IgE antibodies via the human Mas-related G-protein-coupled receptor member X2 (MRGPRX2). In light of this new insight into the patho-mechanism of pseudo-allergic adverse drug reactions, in which as drug-receptor interaction results in anaphylaxis like symptoms, we critically reviewed the literature on NMBA-induced perioperative anaphylaxis. We challenge the dogma that NMBA mainly cause IgE-mediated anaphylaxis via an IgE-mediated mechanism, which is based on studies that consider positive skin test to be specific for IgE-mediated hypersensitivity. Finally, we discuss the question whether MRGPRX2 mediated pseudo-allergic reactions should be re-classified as type A adverse reactions.
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Koo BW, Jung KW, Oh AY, Kim EY, Na HS, Choi ES, Seo KS. Is neuromuscular blocker needed in children undergoing inguinal herniorrhaphy?: A prospective, randomized, and controlled trial. Medicine (Baltimore) 2017; 96:e7259. [PMID: 28658119 PMCID: PMC5500041 DOI: 10.1097/md.0000000000007259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Intraoperative neuromuscular blocker is widely used, but is known to be associated with postoperative residual paralysis, which is known to be associated with increased risk of pulmonary complications. Hence, its use should be individualized and restricted to procedures where it is mandatory. We examined whether not using a neuromuscular blocker affects the surgical conditions in children undergoing inguinal herniorrhaphy. METHODS Anesthesia was induced and maintained with sevoflurane in 60% nitrous oxide, and the airway was maintained using an I-gel. In total, 66 children aged 1 to 6 years were randomized to receive rocuronium (rocuronium group, n = 33) or saline (control group, n = 33); 61 children of them finished the study. A single surgeon who performed the operation rated the surgical condition of each patient on a 4-point scale (1 = poor, 2 = acceptable, 3 = good, and 4 = excellent). Intraoperative patient movement, recovery time, emergence agitation, and postoperative pain scores were evaluated. RESULTS One patient in control group and no patient in rocuronium group showed intraoperative movement. When noninferiority test was done for intraoperative patient movement, with the noninferiority margin of 20%, the difference of absolute risk was 3.3% (95% confidence interval -8.0% to 16.7%) and saline group was noninferior to rocuronium group. All of the patients showed good to excellent surgical conditions, and no difference was found between the 2 groups. The recovery time was shorter in the control group than in the rocuronium group (4.5 ± 1.8 vs 5.6 ± 2.2 minutes, respectively; P = .028). CONCLUSION In children aged 1 to 6 years undergoing inguinal herniorhaphy under sevoflurane anesthesia using an I-gel, not using neuromuscular blocker showed similar intraoperative condition and shortened recovery time compared with using neuromouscular blocker.
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Affiliation(s)
- Bon-Wook Koo
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam
| | - Kyu-Whan Jung
- Department of Surgery, Jeju National University Hospital, Jeju
| | - Ah-Young Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam
- Department of Anesthesiology and Pain Medicine, Seoul National University School of Medicine
| | - Eun-Young Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam
| | - Hyo-Seok Na
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam
| | - Eun-Su Choi
- Department of Anesthesiology and Pain Medicine, Nowon Eulji Medical Center, Eulji University
| | - Kwang-Suk Seo
- Department of Dental Anesthesiology, Seoul National University Dental Hospital, Seoul, Korea
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Abstract
Abstract
Postoperative residual neuromuscular block has been recognized as a potential problem for decades, and it remains so today. Traditional pharmacologic antagonists (anticholinesterases) are ineffective in reversing profound and deep levels of neuromuscular block; at the opposite end of the recovery curve close to full recovery, anticholinesterases may induce paradoxical muscle weakness. The new selective relaxant-binding agent sugammadex can reverse any depth of block from aminosteroid (but not benzylisoquinolinium) relaxants; however, the effective dose to be administered should be chosen based on objective monitoring of the depth of neuromuscular block.
To guide appropriate perioperative management, neuromuscular function assessment with a peripheral nerve stimulator is mandatory. Although in many settings, subjective (visual and tactile) evaluation of muscle responses is used, such evaluation has had limited success in preventing the occurrence of residual paralysis. Clinical evaluations of return of muscle strength (head lift and grip strength) or respiratory parameters (tidal volume and vital capacity) are equally insensitive at detecting neuromuscular weakness. Objective measurement (a train-of-four ratio greater than 0.90) is the only method to determine appropriate timing of tracheal extubation and ensure normal muscle function and patient safety.
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Freundlich RE, Duggal NM, Housey M, Tremper TT, Engoren MC, Kheterpal S. Intraoperative medications associated with hemodynamically significant anaphylaxis. J Clin Anesth 2016; 35:415-423. [PMID: 27871567 DOI: 10.1016/j.jclinane.2016.09.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 08/25/2016] [Accepted: 09/13/2016] [Indexed: 12/26/2022]
Abstract
STUDY OBJECTIVE To facilitate the identification of drugs and patient factors associated with hemodynamically significant anaphylaxis. DESIGN Using an existing database containing complete perioperative records, instances of hemodynamically significant anaphylaxis were identified using a physiologic and treatment-based screening algorithm. All cases were manually reviewed by 2 clinicians, with a third adjudicating disagreements, and confirmed cases were matched 3:1 with control cases. Intraoperative medications given in instances of hemodynamically significant anaphylaxis and patient risk factors were compared with control cases. SETTING University of Michigan Hospital, a large, tertiary care hospital. PATIENTS All adult patients undergoing surgery between January 1, 2004, and January 5, 2015. INTERVENTIONS None. MEASUREMENTS Incidence of hemodynamically significant anaphylaxis during anesthesia. Patient risk factors and intraoperative medications associated with hemodynamically significant anaphylaxis. MAIN RESULTS Hemodynamically significant anaphylaxis occurred in 55 of 461 986 cases (1 in 8400). Hemodynamically significant anaphylaxis occurred in 52 patients, with 1 patient experiencing 3 instances and another patient 2 instances. Only 1 drug was associated with an increased risk of hemodynamically significant anaphylaxis: protamine (odds ratio, 11.78; 95% confidence interval, 1.40-99.26; P=.0233). No category of drugs was associated with increased risk. Of patient risk factors, only personal history of anaphylaxis was associated with an increased risk (odds ratio, 77.1; 95% confidence interval, 10.46-567.69; P=<.0001). Postoperative follow-up and evaluation of patients were low at our institution. A serum tryptase level was sent in only 49% of cases, and 41% of levels were positive, an overall positive rate of 20% of cases. Following instances of hemodynamically significant anaphylaxis, only 29% of patients were seen and evaluated by an allergist at our institution. CONCLUSIONS Hemodynamically significant anaphylaxis is a rare complication of anesthesia, with an incidence consistent with the existing literature. Contrary to most existing literature, only protamine was associated with increased risk. A personal history of anaphylaxis appears to best predict risk of hemodynamically significant anaphylaxis.
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Affiliation(s)
- Robert E Freundlich
- Department of Anesthesiology, Vanderbilt University Medical Center, 1211 21st Ave S, Suite 526, Nashville, TN 37212.
| | - Neal M Duggal
- Department of Anesthesiology, University of Michigan, 1500 E Medical Center Dr, U1H247, SPC 5048, Ann Arbor, MI 48109.
| | - Michelle Housey
- Department of Anesthesiology, University of Michigan, 1500 E Medical Center Dr, U1H247, SPC 5048, Ann Arbor, MI 48109.
| | - Tyler T Tremper
- Department of Anesthesiology, University of Michigan, 1500 E Medical Center Dr, U1H247, SPC 5048, Ann Arbor, MI 48109.
| | - Milo C Engoren
- Department of Anesthesiology, University of Michigan, 1500 E Medical Center Dr, U1H247, SPC 5048, Ann Arbor, MI 48109.
| | - Sachin Kheterpal
- Department of Anesthesiology, University of Michigan, 1500 E Medical Center Dr, U1H247, SPC 5048, Ann Arbor, MI 48109.
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Kuhlen JL, Camargo CA, Balekian DS, Blumenthal KG, Guyer A, Morris T, Long A, Banerji A. Antibiotics Are the Most Commonly Identified Cause of Perioperative Hypersensitivity Reactions. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2016; 4:697-704. [PMID: 27039234 DOI: 10.1016/j.jaip.2016.02.008] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 02/15/2016] [Accepted: 02/19/2016] [Indexed: 01/13/2023]
Abstract
BACKGROUND Hypersensitivity reactions (HSRs) during the perioperative period are unpredictable and can be life threatening. Prospective studies for the evaluation of perioperative HSRs are lacking, and data on causative agents vary between different studies. OBJECTIVE The objective of this study was to prospectively determine the success of a comprehensive allergy evaluation plan for patients with HSRs during anesthesia, including identification of a causative agent and outcomes during subsequent anesthesia exposure. METHODS All patients referred for a perioperative HSR between November 2013 and March 2015, from a Boston teaching hospital, were evaluated using a standardized protocol with skin testing (ST) within 6 months of HSR. Comprehensive allergy evaluation included collection of patient information, including characteristics of HSR during anesthesia. We reviewed the results of ST and/or test doses for all potential causative medications Event-related tryptase levels were reviewed when available. RESULTS Over 17 months, 25 patients completed the comprehensive allergy evaluation. Fifty-two percent (13 of 25) were female with a median age of 52 (interquartile range 43-66) years. The most frequently observed HSR systems were cutaneous (68%), cardiovascular (64%), and pulmonary (24%). A culprit drug, defined as a positive ST, was identified in 36% (9 of 25) of patients. The most common agent identified was cefazolin (6 of 9). After our comprehensive evaluation and management plan, 7 (7 of 8, 88%) patients tolerated subsequent anesthesia. CONCLUSIONS Cefazolin was the most commonly identified cause of a perioperative HSR in our study population. Skin testing patients within 6 months of a perioperative HSR may improve the odds of finding a positive result. Tolerance of subsequent anesthesia is generally achieved in patients undergoing our comprehensive evaluation.
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Affiliation(s)
- James L Kuhlen
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass.
| | - Carlos A Camargo
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Mass
| | - Diana S Balekian
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass; Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Mass
| | - Autumn Guyer
- Division of Allergy and Inflammation, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Mass; Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California San Francisco, San Francisco, Calif
| | - Theresa Morris
- Department of Anesthesia, Massachusetts General Hospital, Boston, Mass
| | - Aidan Long
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass
| | - Aleena Banerji
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass
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Takazawa T, Mitsuhata H, Mertes PM. Sugammadex and rocuronium-induced anaphylaxis. J Anesth 2015; 30:290-7. [PMID: 26646837 PMCID: PMC4819478 DOI: 10.1007/s00540-015-2105-x] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Accepted: 11/11/2015] [Indexed: 12/19/2022]
Abstract
Perioperative anaphylaxis is a life-threatening clinical condition that is typically the result of drugs or substances used for anesthesia or surgery. The most common cause of anaphylaxis during anesthesia is reportedly neuromuscular blocking agents. Of the many muscle relaxants that are clinically available, rocuronium is becoming popular in many countries. Recent studies have demonstrated that succinylcholine (but also rocuronium use) is associated with a relatively high rate of IgE-mediated anaphylaxis compared with other muscle relaxant agents. Sugammadex is widely used for reversal of the effects of steroidal neuromuscular blocking agents, such as rocuronium and vecuronium. Confirmed cases of allergic reactions to clinical doses of sugammadex have also been recently reported. Given these circumstances, the number of cases of hypersensitivity to either sugammadex or rocuronium is likely to increase. Thus, anesthesiologists should be familiar with the epidemiology, mechanisms, and clinical presentations of anaphylaxis induced by these drugs. In this review, we focus on the diagnosis and treatment of anaphylaxis to sugammadex and neuromuscular blocking agents. Moreover, we discuss recent studies in this field, including the diagnostic utility of flow cytometry and improvement of rocuronium-induced anaphylaxis with the use of sugammadex.
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Affiliation(s)
- Tomonori Takazawa
- Department of Anesthesiology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, 371-8511, Japan.
| | - Hiromasa Mitsuhata
- Department of Anesthesiology, Juntendo Tokyo Koto Geriatric Medical Center, 3-3-20 Shinsuna, Koto-Ku, Tokyo, 136-0075, Japan
| | - Paul Michel Mertes
- Service d'anesthésie-réanimation chirurgicale, Nouvel hôpital civil, hôpitaux universitaires de Strasbourg, 1, place de l'Hôpital, BP 426, 67091, Strasbourg Cedex, France
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Blanca-López N, del Carmen Plaza-Serón M, Cornejo-García JA, Perkins JR, Canto G, Blanca M. Drug-Induced Anaphylaxis. CURRENT TREATMENT OPTIONS IN ALLERGY 2015. [DOI: 10.1007/s40521-015-0055-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Otani IM, Kuhlen JL, Blumenthal KG, Guyer A, Banerji A. A role for vancomycin epicutaneous skin testing in the evaluation of perioperative anaphylaxis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2015; 3:984-5. [PMID: 26246124 DOI: 10.1016/j.jaip.2015.06.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Revised: 06/02/2015] [Accepted: 06/22/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Iris M Otani
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass.
| | - James L Kuhlen
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass; Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Mass
| | - Autumn Guyer
- Division of Allergy and Inflammation, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Aleena Banerji
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass
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Drug hypersensitivity reactions: more basic and clinical research is needed. Curr Opin Allergy Clin Immunol 2015; 15:273-6. [PMID: 26110675 DOI: 10.1097/aci.0000000000000182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kannan JA, Bernstein JA. Perioperative anaphylaxis: diagnosis, evaluation, and management. Immunol Allergy Clin North Am 2015; 35:321-34. [PMID: 25841554 DOI: 10.1016/j.iac.2015.01.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Perioperative anaphylaxis can occur during or after surgery and can have life-threatening consequences. As anesthesia protocols become more complex and incorporate multiple agents to regulate physiologic processes intraoperatively, perioperative anaphylaxis is becoming increasingly recognized. The allergist should obtain detailed records from the anesthesiologist in order to perform appropriate testing to identify the likely causative agents. Testing should ideally be performed 4 to 6 weeks after the reaction to account for a refractory period after mast cell activation. This article includes 2 cases of perioperative anaphylaxis and reviews the historical elements that must be considered after a reaction has occurred.
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Affiliation(s)
- Jennifer A Kannan
- Division of Immunology, Allergy and Rheumatology, Department of Medicine, University of Cincinnati College of Medicine, 3255 Eden Avenue, Suite 350, ML 563, Cincinnati, OH 45267-0563, USA
| | - Jonathan A Bernstein
- Division of Immunology, Allergy and Rheumatology, Department of Medicine, University of Cincinnati College of Medicine, 3255 Eden Avenue, Suite 350, ML 563, Cincinnati, OH 45267-0563, USA; Bernstein Clinical Research Center, 8444 Winton Road, Cincinnati, OH 45231, USA.
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