Perioperative Anaphylaxis: Evaluation and Management

2023 Beijing Health Data Science Summit

The 5th annual Beijing Health Data Science Summit, organized by the National Institute of Health Data Science at Peking University, recently concluded with resounding success. This year, the summit aimed to foster collaboration among researchers, practitioners, and stakeholders in the field of health data science to advance the use of data for better health outcomes. One significant highlight of this year's summit was the introduction of the Abstract Competition, organized by Health Data Science, a Science Partner Journal, which focused on the use of cutting-edge data science methodologies, particularly the application of artificial intelligence in the healthcare scenarios. The competition provided a platform for researchers to showcase their groundbreaking work and innovations. In total, the summit received 61 abstract submissions. Following a rigorous evaluation process by the Abstract Review Committee, eight exceptional abstracts were selected to compete in the final round and give presentations in the Abstract Competition. The winners of the Abstract Competition are as follows:•First Prize: "Interpretable Machine Learning for Predicting Outcomes of Childhood Kawasaki Disease: Electronic Health Record Analysis" presented by researchers from the Chinese Academy of Medical Sciences, Peking Union Medical College, and Chongqing Medical University (presenter Yifan Duan).•Second Prize: "Survival Disparities among Mobility Patterns of Patients with Cancer: A Population-Based Study" presented by a team from Peking University (presenter Fengyu Wen).•Third Prize: "Deep Learning-Based Real-Time Predictive Model for the Development of Acute Stroke" presented by researchers from Beijing Tiantan Hospital (presenter Lan Lan). We extend our heartfelt gratitude to the esteemed panel of judges whose expertise and dedication ensured the fairness and quality of the competition. The judging panel included Jiebo Luo from the University of Rochester (chair), Shenda Hong from Peking University, Xiaozhong Liu from Worcester Polytechnic Institute, Liu Yang from Hong Kong Baptist University, Ma Jianzhu from Tsinghua University, Ting Ma from Harbin Institute of Technology, and Jian Tang from Mila-Quebec Artificial Intelligence Institute. We wish to convey our deep appreciation to Zixuan He and Haoyang Hong for their invaluable assistance in the meticulous planning and execution of the event. As the 2023 Beijing Health Data Science Summit comes to a close, we look forward to welcoming all participants to join us in 2024. Together, we will continue to advance the frontiers of health data science and work toward a healthier future for all.

Relationship between perioperative anaphylaxis and history of allergies or allergic diseases: A systematic review and meta-analysis with meta-regression

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.

Sustained intraoperative allergic reaction to chlorhexidine: A case report

Physicians should be prepared for the presentation and treatment of an anaphylactic reaction in a patient who has been exposed to chlorhexidine perioperatively and consider a sustained source of allergic exposure when faced with a refractory response to treatment.

Screening potential anaphylactoid components in vinpocetine injection using a high expression Mas-related G-protein-coupled receptor X2 cell membrane chromatography

Vinpocetine injection is often used in clinical treatment of acute cardiovascular and cerebrovascular diseases. However, it was reported that vinpocetine injection caused allergic reactions in clinical use; therefore, its safety needs urgent attention. Until now, research on its sensitization is rarely reported. Here, the components contained in three vinpocetine injections were examined. It was found that besides vinpocetine, the synthetic raw material vincamine, the excipients benzyl alcohol and ethyl p-toluenesulfonate, and the impurities A, B, C, and D, which are excipients specified in the European Pharmacopoeia, were also present in them. Then the Mas-related G-protein-coupled receptor X2 (MRGPRX2)-HEK293 cell membrane chromatography was used to investigate the affinity of them with MRGPRX2 and found that vinpocetine, vincamine, and impurities A, B, C, and D bind to MRGPRX2. Afterwards, these compounds were further used to investigate the local sensitization ability in vivo. The results showed that vinpocetine, vincamine, and impurity C could induce swelling of the paw and decrease body temperature in mice, but only impurity C could cause local skin mast cell degranulation and serum histamine release increase. In vitro, the results also indicated that impurity C could increase intracellular [Ca²⁺ ] in MRGPRX2-HEK293 cells, whereas vinpocetine and vincamine did not. Therefore, the impurity C was the potential anaphylactoid component in vinpocetine injection, which may be one of the reasons for the occurrence of allergic reactions in the clinical use of vinpocetine injection. This work provides evidence on the sensitization of impurity C and also contributes to promoting the clinical safety of vinpocetine injection.

Secondary prevention of latex allergy

PURPOSE OF REVIEW

The present review addresses the secondary prevention in healthcare worker, healthcare setting, and in patients outside the healthcare setting.

RECENT FINDINGS

There is sufficient knowledge of the broad aetiology of latex allergy for secondary preventive programmes to be widely adopted. Currently, avoidance of latex-containing surgical products is mandatory in the care of sensitized patients. They should also have a list of occult sources of natural rubber latex exposure and cross-reacting fruits. During all health-care procedures latex allergic patients should be treated in a 'latex-free' environment. Specific sublingual immunotherapy has been suggested as a suitable therapeutic option. It can be offered, in addition to symptomatic treatment, to selected patients, when avoidance measures are not feasible or effective. The use of omalizumab could also be extended as an adjunct to latex immunotherapy.

SUMMARY

Despite of the progress made in the secondary prevention of latex allergy, the disease still continues to be a global health problem.

Case Report: Takotsubo Syndrome Induced by Severe Anaphylactic Reaction During Anesthesia Induction and Subsequent High-Dose Epinephrine Resuscitation

Takotsubo syndrome (TTS) is a type of non-ischemic cardiomyopathy characterized by an acute reversible left ventricular dysfunction with typical apical ballooning, usually with subsequent complete recovery. Early diagnosis and prompt treatment are of great essence. Herein, we described a case of TTS of a patient who was scheduled initially for laparoscopic endometrial cancer staging. The 69-year-old woman presented with cardiogenic shock induced by the severe anaphylactic reaction to the antibiotics during anesthesia induction. Cardiopulmonary resuscitation (CPR) was implemented while several boluses of 1 mg epinephrine were injected. After the return of spontaneous circulation, a large number of orange peel-like rash appeared on the head, face, neck, and trunk of the patient. Transesophageal echocardiography (TEE) revealed diffused decreased left ventricular systolic function. Therefore, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and intra-aortic balloon pump (IABP) were applied in the intensive care unit. Biomarkers like cardiac troponin I (cTnI) subsequently decreased with improved cardiac insufficiency. Finally, the patient was discharged in good condition. This case demonstrated that TTS could be secondary to severe anaphylactic shock and exogenous catecholamines. With the consideration of the reversible condition and predictable recovery of TTS, early vigilance and advanced life support devices should be necessary.

Clinical characteristics and allergen detection of perioperative anaphylaxis: a 12-year retrospective analysis from an anesthesia clinic in China

Abstract

Background

Anaphylaxis during anesthesia is a rare but often a potentially life-threatening event for patients. Identifying culprit agents responsible for anaphylaxis is of great important for avoiding potential re-exposure to allergens, but it poses great challenge for anesthetists. This retrospective study aimed to analyze the culprits of patients with a history of perioperative anaphylaxis referred to an anesthesia allergy clinic in China, and to evaluate the role of allergy diagnostic tests in clinical practice.

Methods

A total of 145 patients (102 female/43 male) who attended the Anesthesia Allergy Clinic for allergen detection between 1 January 2009 and 31 December 2020 were reviewed retrospectively. Clinical characteristics, results of allergy diagnostic tests including skin, and/or basophil activation tests, and the incidence of repeat anaphylaxis after use of recommended alternative anesthetics were obtained.

Results

Of these 145 patients, 109 patients (75.2%, 74 females/35 males) were determined to experience perioperative anaphylaxis. The most common presenting clinical feature was cardiovascular manifestations (n = 63, 57.8%). According to diagnostic work up, the most common causative agents for perioperative anaphylaxis were neuromuscular blocking agents (n = 35, 32.1%). After diagnostic work up, 52 patients underwent repeat anesthesia. None of these patients experienced recurrent anaphylaxis.

Conclusions

This study suggests that neuromuscular blocking agents are the main cause of perioperative anaphylaxis. For patients with perioperative anaphylaxis, allergy diagnostic tests are essential to identify causative agents, and to find suitable alternative drugs for the future planning of subsequent anesthetics.