Perioperative anaphylaxis: what should be known?

Epidemiology and Triggers of Severe Perioperative Anaphylaxis: An 8-Year Single-Center Study

OBJECTIVE

To determine the features, rescue measures, outcomes, re-allergic reactions, and independent risk factors associated with severe anaphylaxis during surgery.

DESIGN

Instances of severe perioperative anaphylaxis were identified through perioperative electronic records, adverse event reporting records, and surveys of anesthesiologists. Confirmed cases were randomly matched 4:1 with control cases on the same operation day. Patient risk factors, surgery type, anesthetic technique, and perioperative medications, fluids, and blood transfusions were given in instances of severe perioperative anaphylaxis were compared with control cases.

SETTING

A tertiary hospital in China.

PATIENTS

All patients undergoing surgery and anesthesia in the operating room from January 2014 to February 2022.

MEASUREMENTS

Incidence and the independent risk factors for severe perioperative anaphylaxis.

MAIN RESULTS

Ninety-seven patients experienced severe perioperative allergic responses during the 266,033 surgeries performed, with an incidence rate of 3.6 per 10,000. Three of 97 anaphylaxis patients experienced a severe allergic reaction again during the second surgery. The nested case-control study revealed that the independent triggers during surgery were allergy history (odds ratio 5.23; 95% confidence interval [CI], 2.35-11.68; p < 0.001), cisatracurium use (odds ratio 5.03; 95% CI, 1.22-20.70; p < 0.001), hydroxyethyl starch 130/0.4 use (odds ratio 5.36; 95% CI, 2.99-9.60; p =0.025), and allogeneic plasma (odds ratio 11.02; 95% CI, 3.78-35.95; p < 0.001).

CONCLUSIONS

Perioperative severe anaphylaxis is a rare but life-threatening complication. Previous allergic history, cisatracurium, hydroxyethyl starch 130/0.4, and allogeneic plasma may be the independent triggers. Early diagnosis of anaphylaxis and the timely administration of epinephrine are critical to allergic treatment. Avoiding exposure to allergens is effective for preventing severe allergic responses and the efficacy of glucocorticoids and antihistamines is controversial.

Early Use of ECMO for Refractory Kounis Syndrome Concealed by General Anesthesia—A Case Report

A 46-year-old woman demonstrated refractory Kounis syndrome (KS) after induction of anesthesia. Despite conventional management of anaphylaxis and advanced cardiac life support, her cardiovascular function continued to deteriorate until she had a cardiac arrest, and after extracorporeal membrane oxygenation (ECMO) therapy, electrical cardiac activity reappeared. A large number of patients with KS—“allergic angina syndrome”—has been known to recover well with vasodilators; however, this patient showed antibiotics-induced refractory KS during general anesthesia. Severe bronchospasms with desaturation appeared as initial anaphylactic features; however, these did not respond to conventional treatment for anaphylaxis. Patient’s hemodynamic signs eventually worsened, leading to cardiac arrest despite ephedrine administration and chest compressions. During cardiopulmonary cerebral resuscitation, the central line was secured, and epinephrine, atropine, as well as sodium bicarbonate were administered repeatedly; nevertheless, cardiac arrest was sustained. After initiation of veno-arterial ECMO, atrial fibrillation was observed, which was later converted to sinus tachycardia by electrical cardioversions and amiodarone. Coronary angiography was performed before the patient was admitted to the intensive care unit; there were no indications of an impending cardiac arrest. The patient was discharged uneventfully owing to early use of ECMO despite the emergence of KS symptoms that were initially masked by anesthesia but later worsened abruptly.

Perioperative Anaphylaxis

Perioperative anaphylaxis is a potentially life-threatening and under-recognized event most commonly caused by antibiotics, neuromuscular blocking agents, dyes, latex, and disinfectants. This review provides updates in the epidemiology and pathogenesis of perioperative anaphylaxis, discusses culprit agents, and highlights the tenets of management including a comprehensive allergy evaluation.

Diagnostic performance of serial serum total tryptase measurement to differentiate positive from negative allergy testing among patients with suspected perioperative hypersensitivity

BACKGROUND

Serum total tryptase has been shown to increase during acute allergic reactions (acute tryptase, T_A ); however, few studies have investigated the values of T_A or a combination of T_A and baseline tryptase (T_B ) to discriminate positive from negative testing in perioperative hypersensitivity reaction (POH) allergy work up. The aim of this study was to determine the diagnostic performance of T_A in order to differentiate positive from negative allergy testing suspected POH and analyze the diagnostic performance of serial tryptase levels using several formulas.

METHODS

All patients from the University hospital of Montpellier and Strasbourg, France who presented with suspected POH and underwent complete drug allergy work-up between March 2011 and December 2019 with available T_A and T_B were included. Four formulas, including a change in T_A >11 (F1), or >2+1.2xT_B (F2), or >3+T_B (F3), or >120%T_B (F4), were applied.

RESULTS

One hundred and sixty-two patients were included, and 131 of them (80.8%) had grade III or IV reactions. Ninety patients had positive allergy testing. The optimal cut-off value of T_A to distinguish positive from negative allergy testing patients was 9.8 μg/L with an AUC of 0.817 (95%CI: 0.752-0.882, p<0.001). The 93% PPV threshold for T_A was 33 μg/L (95.8% specificity). Paired tryptase levels according to formulas F2 and F3 yielded the highest Youden index (0.54 and 0.53, respectively).

CONCLUSION

The optimal cut-off point for T_A for distinguishing positive from negative allergy testing suspected POH was 9.8 μg/L. T_A value of 33 μg/L was required to achieve >90% PPV.

Epidemiology of suspected life-threatening perioperative anaphylaxis: a cross-sectional multicentre study in China

BACKGROUND

Perioperative anaphylaxis is relatively rare but can be life-threatening. The incidence in China is unknown and may differ from other global geographic regions. This study was therefore designed to understand the incidence of perioperative anaphylaxis in China.

METHODS

We enrolled 112 tertiary care hospitals from seven distinct geographic areas in mainland China. We collected information about Ring and Messmer III and IV reactions from September 2018 to August 2019. A collaborative educational learning network was used to reduce diagnostic errors. Information about patient characteristics, clinical features, treatment, and clinical outcomes were recorded and analysed.

RESULTS

A total of 447 cases of 5 078 118 surgical procedures met inclusion criteria. The incidence of suspected perioperative anaphylaxis throughout China was one in 11 360 anaesthetics (95% confidence interval [CI], with a range of 1:12 521 to 1:10 397). The incidence in South China was higher (one in 6050; 95% CI, from 1:8013 to 1:4859) than in Northeast China (one in 19 262; 95% CI, from 1:33 088 to 1:13 585) (P<0.01) with an increasing trend from the north to the south. The most common clinical manifestations were hypotension (91.1%) and tachycardia (65.3%). The majority of patients (83.4%) were given epinephrine. A total of 27 patients (6.0%) required cardiopulmonary resuscitation. Ultimately, nine patients died (2.0%).

CONCLUSIONS

This nationwide survey showed an incidence of perioperative anaphylaxis of one in 11 360, but this varied significantly by region. The underlying reason for this pattern remains unknown and could be attributable to environmental or genetic influences, which requires further investigation.

CLINICAL REGISTRY NUMBER

ChiCTR1900025956.

[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]

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.

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

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.

[Update on perioperative hypersensitivity reactions: joint document of the Brazilian Society of Anesthesiology (SBA) and Brazilian Association of Allergy and Immunology (ASBAI) - Part I: post-crisis guidelines and treatment]

Experts from the Brazilian Association of Allergy and Immunology (ASBAI) and the Brazilian Society of Anesthesiology (SBA) interested in the issue of perioperative anaphylaxis, and aiming to strengthen the collaboration between the two societies, combined efforts to study the topic and to prepare a joint document to guide specialists in both areas. The purpose of the present series of two articles was to report the most recent evidence based on the collaborative assessment between both societies. This first article will consider the updated definitions, treatment and guidelines after a perioperative crisis. The following article will discuss the major etiologic agents, how to proceed with the investigation, and the appropriate tests.

A systematic review and meta-analysis of antibiotic prophylaxis in skin graft surgery: A protocol

Introduction

There is little evidence-based guidance on the use of prophylactic antibiotics in skin surgery; whilst antibiotics may protect against surgical site infections (SSI), they have associated side effects, increase the risk of adverse events, and can propagate antibiotic resistance. We present a protocol for a systematic review to establish whether the benefit of prophylactic antibiotics overrides the risk, for patients undergoing autograft surgery.

Methods

The systematic review will be registered a priori on researchregistry.com and will be conducted in line with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). A search strategy will be devised to investigate 'skin graft surgery and use of antibiotics'. The following electronic databases will be searched, 1979-2018: PubMed, MEDLINE®, EMBASE, SCOPUS, CINAHL, PsychINFO, SciELO, The Cochrane Library, including the Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effect (DARE), the Cochrane Methodology Register, Health Technology Assessment Database, the NHS Economic Evaluation Databases and Cochrane Groups, ClinicalTrials.gov, Current Controlled Trials Database, the World Health Organisation (WHO) International Clinical Trials Registry Platform, UpToDate.com, NHS Evidence and the York Centre for Reviews and Dissemination. Grey literature will be searched. All comparative study designs reporting on the use of antibiotics in skin graft surgery will be considered for inclusion, namely randomized controlled trials (RCTs). Two trained independent teams will screen all titles and abstracts, followed by relevant full texts, for eligibility. Data will be extracted under standardized extraction fields into a preformatted database. Note will be made of the indication for skin graft surgery (traumatic, congenital, malignant, benign), the graft site (head & neck, trunk, upper extremities, lower extremities), type of skin graft (split thickness, full-thickness). The primary outcome will be occurrence of SSI at the donor and/or recipient sites. Secondary outcomes, if reported, will include: length of hospital stay, revision surgery required, cost of medical care, time to wound healing and cosmetic outcome.

Ethics and dissemination

The systematic review will be published in a peer-reviewed journal and presented at national and international meetings within fields of plastic, reconstructive, and aesthetic surgery. The work will be disseminated electronically and in print. Brief reports of the review and findings will be disseminated to interested parties through email and direct communication. The review aims to guide healthcare practice and policy.

An EAACI position paper on the investigation of perioperative immediate hypersensitivity reactions

Perioperative immediate hypersensitivity reactions are rare. Subsequent allergy investigation is complicated by multiple simultaneous drug exposures, the use of drugs with potent effects and the many differential diagnoses to hypersensitivity in the perioperative setting. The approach to the investigation of these complex reactions is not standardized, and it is becoming increasingly apparent that collaboration between experts in the field of allergy/immunology/dermatology and anaesthesiology is needed to provide the best possible care for these patients. The EAACI task force behind this position paper has therefore combined the expertise of allergists, immunologists and anaesthesiologists. The aims of this position paper were to provide recommendations for the investigation of immediate-type perioperative hypersensitivity reactions and to provide practical information that can assist clinicians in planning and carrying out investigations.

Anaesthetic management of patients with pre-existing allergic conditions: a narrative review

This narrative review seeks to distinguish the clinical patterns of pre-existing allergic conditions from other confounding non-allergic clinical entities, and to identify the potential related risks and facilitate their perioperative management. Follow-up investigation should be performed after a perioperative immediate hypersensitivity to establish a diagnosis and provide advice for subsequent anaesthetics, the main risk factor for perioperative immunoglobulin E (IgE)-mediated anaphylaxis being a previous uninvestigated perioperative immediate hypersensitivity reaction. The concept of cross-reactivity between drugs used in the perioperative setting and food is often quoted, but usually not supported by evidence. There is no reason to avoid propofol in egg, soy, or peanut allergy. The allergenic determinants have been characterised for fish, shellfish, and povidone iodine, but remain unknown for iodinated contrast agents. Iodinated drugs may be used in seafood allergy. Evidence supporting the risk for protamine allergy in fish allergy and in neutral protamine Hagedorn insulin use is lacking. Conversely, cross-reactivity to gelatin-based colloid may occur in α-gal syndrome. Atopy and allergic asthma along with other non-allergic conditions, such as NSAID-exacerbated respiratory disease, chronic urticaria, mastocytosis, and hereditary or acquired angioedema, are not risk factors for IgE-mediated drug allergy, but there is a perioperative risk associated with the potential for exacerbation of the various conditions.

The Incidence and Nature of Allergic and Anaphylactic Reactions During Pediatric Procedural Sedation: A Report From the Pediatric Sedation Research Consortium

BACKGROUND AND OBJECTIVES

Anaphylaxis is rare but life-threatening. Its incidence during pediatric procedural sedation outside of the operating room is unknown. We used data from the Pediatric Sedation Research Consortium (PSRC) to determine the incidence and nature of allergic and anaphylactic reactions in this practice.

METHODS

A retrospective observational study of prospectively collected information in the PSRC's multicenter database was performed. Cases of allergic reaction were identified. Because anaphylaxis is not a listed complication in the PSRC database, all cases for which allergic reaction was noted were reviewed for the occurrence of other complications or interventions that would suggest at least 2 organ system derangements consistent with anaphylaxis as well as for practitioner commentary stating the occurrence of anaphylaxis. Descriptive analyses of demographic information and summary statistics were performed, and multiple logistic regression analysis was used to evaluate associations between the occurrence of allergic reactions and medications.

RESULTS

During the study period, 227 833 cases were entered into the PSRC database. There were 54 cases of allergic reaction (incidence 1:4219); 6 were consistent with anaphylaxis (incidence 1:37 972). A significant association between the development of allergic reaction and 4 sedative and/or analgesic medications was noted: midazolam (odds ratio [OR] 2.2; confidence interval [CI] 1.2-3.9), ketamine (OR 3.8; CI 2.1-7.1), methohexital (OR 48.8; CI 14.9-159.9), and morphine (OR 4.4; CI 1.04-18.2). There were no mortalities.

CONCLUSIONS

Allergic reactions and anaphylaxis during pediatric procedural sedation are rare. In this study, the development of allergic reactions was significantly associated with the use of midazolam, ketamine, methohexital, and morphine.

Association between sugammadex and anaphylaxis in pediatric patients: A nested case-control study using a national inpatient database

BACKGROUND

Sugammadex is used as a reversal drug during anesthesia. Although several case reports have described anaphylaxis following sugammadex infusion, little is known about the relationship between sugammadex and anaphylaxis, particularly in pediatric patients.

AIMS

The aim of this retrospective study was to investigate the association between sugammadex and in-hospital anaphylaxis in pediatric patients who underwent general anesthesia.

METHODS

We identified patients who underwent general anesthesia in a Japanese national inpatient database between July 2010 and March 2016. We conducted 1-4 case-control matching between patients with and without perioperative anaphylaxis. We calculated the adjusted odds ratio for sugammadex use and occurrence of anaphylaxis, using a conditional logistic regression analysis with adjustment for duration of anesthesia, antibiotics, and blood transfusions.

RESULTS

Among 835 405 patients who underwent general anesthesia, we identified 149 (0.018%) patients with anaphylactic shock and 472 (0.056%) with a combination of anaphylaxis associated signs/symptoms and skin lesions. Sugammadex use was not significantly associated with anaphylactic shock (odds ratio, 0.80; 95% confidence interval, 0.53-1.21; P = .29) or the combination of anaphylaxis associated signs/symptoms and skin lesions (odds ratio, 1.25; 95% confidence interval, 0.97-1.60; P = .08).

CONCLUSION

The present study showed no significant association between sugammadex and perioperative anaphylaxis in pediatric patients who underwent general anesthesia.

Perioperative drug reactions - practical recommendations for allergy testing and patient management

Background

Allergy testing for perioperative drug reactions poses a particular diagnostic challenge. Neuromuscular blocking agents (NMBA) and antibiotics are among the most common triggers. In principle, however, any drug administered perioperatively is capable of causing a hypersensitivity reaction.

Methods

This article is an overview of selected scientific articles and is based on research in PubMed, specialist databases, and guidelines.

Results

Besides patient's history and laboratory tests (the latter being feasible to only a limited extent), skin tests play a particularly important role. To obtain clinical relevant results, profound knowledge on the best point in time for testing, the drug concentrations to be used, how to perform tests correctly, and the assessment criteria is of special importance.

Conclusion

Final outcomes of the diagnostic procedures should be providing thorough information of the patient about the findings, drugs that should be avoided in the future as well as alternative preparations, and, if necessary, preventive measures to be taken in the event of further surgical interventions.

Two Consecutive Preoperative Cardiac Arrests Involving Vancomycin in a Patient Presenting for Hip Disarticulation: A Case Report

While an abundance of literature exists describing adverse reactions to vancomycin (eg, nausea, vomiting, red man syndrome, acute kidney injury), there is scarce evidence demonstrating vancomycin anaphylactic reactions requiring cardiopulmonary resuscitation. We report a case of a patient who had 2 separate preoperative episodes of cardiac arrest following vancomycin that occurred 4 weeks apart. Both episodes of anaphylaxis required cardiopulmonary resuscitation, which led to a successful patient outcome. We discuss identification and treatment of vancomycin-induced anaphylaxis.

Benzodiazepine Allergy With Anesthesia Administration: A Review of Current Literature

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.

Intraoperative medications associated with hemodynamically significant anaphylaxis

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.