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Tacquard C, Serrier J, Viville S, Chiriac AM, Franchina S, Gouel-Cheron A, Giraudon A, Le Guen M, Le Quang D, Malinovsky JM, Petitpain N, Demoly P, Mertes PM. Epidemiology of perioperative anaphylaxis in France in 2017-2018: the 11th GERAP survey. Br J Anaesth 2024; 132:1230-1237. [PMID: 38493055 PMCID: PMC11130666 DOI: 10.1016/j.bja.2024.01.044] [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: 11/04/2023] [Revised: 12/21/2023] [Accepted: 01/28/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND Perioperative anaphylaxis is rare but is associated with significant morbidity. This complication has been well described in France by the GERAP (Groupe d'Etude des Réactions Anaphylactiques Périopératoires), a network focused on its study. The epidemiology of perioperative anaphylaxis is evolving, influenced by environmental factors and clinical practice. The aim of this study was to update the epidemiology of perioperative anaphylaxis in France. METHODS This multicentre retrospective study was performed in 26 allergy clinics of the GERAP network in 2017-8. RESULTS There were 765 patients with perioperative anaphylaxis included. Most cases were severe, with 428 (56%) reactions graded as 3 or 4 according to the Ring and Messmer classification. Skin test results were available for 676 patients, with a culprit agent identified in 471 cases (70%). Neuromuscular blocking agents were the main cause of perioperative anaphylaxis (n=281; 60%), followed by antibiotics (n=118; 25%) and patent blue dye (n=11; 2%). Cefazolin was the main antibiotic responsible for perioperative anaphylaxis (52% of antibiotic-related reactions). Suxamethonium and rocuronium were the main neuromuscular blocking agents responsible for perioperative anaphylaxis with 7.1 (6.1-8.4) and 5.6 (4.2-7.4) reactions per 100,000 vials sold, respectively, whereas cefazolin-related cases were estimated at 0.7 (0.5-0.9) reactions per 100,000 vials sold. CONCLUSIONS Our results confirm that most commonly identified triggering agents remain neuromuscular blocking agents. Reactions to antibiotics, particularly cefazolin, are becoming increasingly frequent. The origin of sensitisation to cefazolin is unknown, as no cross-sensitisation has been described, and it should be the subject of further study. Perioperative anaphylaxis should be followed over the years and understood given the changing triggers. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov (NCT04654923).
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Affiliation(s)
- Charles Tacquard
- Department of Anesthesia and Intensive Care, Strasbourg University Hospital, Strasbourg, France.
| | - Julien Serrier
- Department of Immunology and Histocompatibility, Caen University Hospital, Caen, France
| | - Simon Viville
- Department of Anesthesia and Intensive Care, Strasbourg University Hospital, Strasbourg, France
| | - Anca-Mirela Chiriac
- Department of Pulmonology, Division of Allergy, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, IDESP, University of Montpellier, Montpellier, France
| | - Sébastien Franchina
- Perioperative Allergic Reaction Exploration Unit, Department of Anesthesia and Intensive Care, Rouen University Hospital, Rouen, France
| | - Aurélie Gouel-Cheron
- Paris City University, Paris, France; Department of Anaesthesiology and Critical Care Medicine, Bichat Hospital, AP-HP, Paris, France; Antibody in Therapy and Pathology, Pasteur Institute, INSERM, Paris, France
| | - Antoine Giraudon
- Department of Anesthesiology and Critical Care, Bordeaux University Hospital, Bordeaux, France
| | - Morgan Le Guen
- Department of Anesthesia and Pain Medicine, Université de Versailles Saint-Quentin, Versailles, France
| | - Diane Le Quang
- Department of Anaesthesia and Intensive Care, Lyon Sud University Hospital, Hospices Civils de Lyon, Lyon, France
| | | | - Nadine Petitpain
- Regional Centre of Pharmacovigilance, University Hospital of Nancy, Nancy, France
| | - Pascal Demoly
- Department of Pulmonology, Division of Allergy, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, IDESP, University of Montpellier, Montpellier, France
| | - Paul M Mertes
- Department of Anesthesia and Intensive Care, Strasbourg University Hospital, Strasbourg, France
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Mertes PM, Tacquard C. Perioperative anaphylaxis: when the allergological work-up goes negative. Curr Opin Allergy Clin Immunol 2023; 23:287-293. [PMID: 37357801 DOI: 10.1097/aci.0000000000000912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2023]
Abstract
PURPOSE OF REVIEW Perioperative anaphylaxis (POA) is rare but is associated with significant morbidity and mortality. Patients are referred to the allergist to identify the mechanism of the reaction, the causative agent and make recommendations regarding subsequent anaesthesia. Despite a well conducted allergological evaluation, the causative agent is not found in 30-60% of these reactions, leaving patients without a well established diagnosis. RECENT FINDINGS Several mechanisms can induce POA. In addition to the well known IgE-mediated reactions, IgG-mediated reaction, MRGPR-X2-related reaction or nonspecific histamine release may be involved. These situations are not easily assessed by the allergological workup. SUMMARY When the allergological workup is negative, the situation should be reassessed with the team present at the time of the reaction to confirm the reality of the hypersensitivity reaction and to search for a possible differential diagnosis. If POA is confirmed, the allergological evaluation should be repeated, ensuring proper execution according to current guidelines and including the search for hidden allergens. Specific IgE assays or basophil activation tests may be of interest. In case of negative results, a closely monitored drug challenge test, in coordination with the anaesthesia teams, may be useful to avoid the exclusion of any drug injected during the reaction.
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Affiliation(s)
- Paul-Michel Mertes
- Department of Anesthesia and Intensive Care, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, Team EFS-INSERM U1255, EFS Grand-Est, Strasbourg, France
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Antécédent d’allergie periopératoire : le thiopental était-il le coupable ? ANESTHÉSIE & RÉANIMATION 2023. [DOI: 10.1016/j.anrea.2023.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
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4
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Dejoux A, de Chaisemartin L, Bruhns P, Longrois D, Gouel-Chéron A. Neuromuscular blocking agent induced hypersensitivity reaction exploration: an update. Ugeskr Laeger 2023; 40:95-104. [PMID: 36301083 DOI: 10.1097/eja.0000000000001765] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Acute hypersensitivity reactions (AHRs) occurring in present-day anaesthesia can have severe, sometimes fatal, consequences and their incidence is increasing. The most frequent allergens responsible for AHR during anaesthesia are neuromuscular blocking agents (NMBAs) (70% of the cases) followed by antibiotics (18%), patent blue dye and methylene blue dye (5%), and latex (5%). Following an AHR, strategies for subsequent anaesthetic procedures (especially the choice of an NMBA) may be difficult to formulate due to inconclusive diagnostic analysis in up to 30% of AHRs. Current diagnosis of AHR relies on the detection of mast cell degranulation products and drug-specific type E immunoglobulins (IgE) in order to document an IgE-mediated anaphylaxis (IgE endotype). Nonetheless, other IgE-independent pathways can be involved in AHR, but their detection is not currently available in standard situations. The different mechanisms (endotypes) involved in peri-operative AHR may contribute to the inconclusive diagnostic work-up and this generates uncertainty concerning the culpable drug and strategy for subsequent anaesthetic procedures. This review provides details on the IgE endotype; an update on non-IgE related endotypes and the novel diagnostic tools that could characterise them. This detailed update is intended to provide explicit clinical reasoning tools to the anaesthesiologist faced with an incomplete AHR diagnostic work-up and to facilitate the decision-making process regarding anaesthetic procedures following an AHR to NMBAs.
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Affiliation(s)
- Alice Dejoux
- From the Institut Pasteur, Université de Paris, Unit of Antibodies in Therapy and Pathology, Inserm UMR1222 (AD, LdC, PB, AGC), Immunology Department, DMU BIOGEM, Bichat Hospital, AP-HP (LdC), Université Paris-Saclay, Inserm, Inflammation, Microbiome and Immunosurveillance, Châtenay-Malabry (LdC), Anaesthesiology and Critical Care Medicine Department, DMU PARABOL, Bichat Hospital, AP-HP (DL, AGC), Université de Paris, FHU PROMICE (DL), Anaesthesiology and Critical Care Medicine Department, DMU PARABOL, Bichat-Claude Bernard and Louis Mourier Hospitals, APHP (DL), INSERM1148, Paris, France (DL), and Biostatistics Research Branch, Division of Clinical Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA (AGC)
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5
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Sverrild A, Carruthers J, Murthee KG, Moore A, O'Hehir RE, Puy R, Hew M, Zubrinich C. Diagnostic value of a medical algorithm for investigation of perioperative hypersensitivity reactions. Allergy 2023; 78:225-232. [PMID: 36136057 DOI: 10.1111/all.15526] [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: 03/10/2022] [Revised: 07/29/2022] [Accepted: 08/23/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Evaluation of perioperative hypersensitivity (POH) is challenging, and accurate screening tools are needed to optimize the diagnostic process. We aimed to assess and validate the diagnostic value of a published algorithm (using tryptase and clinical presentation) to identify appropriate individuals for further testing for IgE-mediated POH. METHODS We analysed the clinical presentation (tryptase elevation, cardiovascular, respiratory, skin involvement) of patients proceeding to testing for possible IgE-mediated POH at a single tertiary referral centre, relative to subsequent skin testing and specific IgE results. Clinical presentations by drug class were also determined. RESULTS In 293 consecutive patients, the use of a published algorithm based on one or more of; (i) defined increase in serum tryptase, (ii) involvement of at least two-organ systems, or (iii) presentation with new urticaria and/or angioedema; was highly sensitive [98.8% (CI95: 95.7-99.9%)] but less specific [34.6% (CI95: 25.7-44.4%)] in identifying patients testing positive on skin testing and/or specific IgE. Presentation with cardiovascular symptoms was also sensitive [89.8%(CI95: 84.2-94.0%)], while the combination of respiratory symptoms and increased tryptase was most specific [85.9%(CI95:76.6-92.5%)]. Respiratory involvement was more common in neuromuscular blocking agent allergy, while urticaria/angioedema was more common in antibiotic allergy. CONCLUSION The published algorithm (of tryptase rise, two-organ involvement or new urticaria/angioedema) is highly sensitive, and appropriate as a screening tool to identify patients suitable for testing for IgE-mediated POH.
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Affiliation(s)
- Asger Sverrild
- Allergy, Asthma and Clinical Immunology, Alfred Health, Melbourne, Victoria, Australia
| | - John Carruthers
- Anaesthesiology and Perioperative Medicine, Alfred Health, Melbourne, Victoria, Australia
| | | | - Alice Moore
- Anaesthesiology and Perioperative Medicine, Alfred Health, Melbourne, Victoria, Australia
| | - Robyn Elizabeth O'Hehir
- Allergy, Asthma and Clinical Immunology, Alfred Health, Melbourne, Victoria, Australia.,Department of Immunology and pathology, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Robert Puy
- Department of Medicine, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Mark Hew
- Allergy, Asthma and Clinical Immunology, Alfred Health, Melbourne, Victoria, Australia
| | - Celia Zubrinich
- Allergy, Asthma and Clinical Immunology, Alfred Health, Melbourne, Victoria, Australia
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Abstract
Anesthesiologists routinely manage patients receiving drugs and agents, all of which have the potential for anaphylaxis, the life-threatening presentation of an allergic reaction. Clinicians must be ready to diagnose and manage the acute cardiopulmonary dysfunction that occurs.
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Affiliation(s)
- Charles Tacquard
- Department of Anesthesia and Intensive Care, Strasbourg University Hospital, Strasbourg, France
| | - Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Jerrold H Levy
- Departments of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, North Carolina
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7
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Making a Diagnosis in Allergic Reactions Occurring in the Operating Room. CURRENT TREATMENT OPTIONS IN ALLERGY 2022. [DOI: 10.1007/s40521-022-00321-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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8
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Abstract
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.
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Affiliation(s)
- Mitchell M Pitlick
- Division of Allergic Diseases, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, USA.
| | - Gerald W Volcheck
- Division of Allergic Diseases, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, USA
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Srisuwatchari W, Tacquard CA, Borushko A, Viville S, Stenger R, Ehrhard Y, Malinovsky JM, Mertes PM, Demoly P, Chiriac AM. Diagnostic performance of serial serum total tryptase measurement to differentiate positive from negative allergy testing among patients with suspected perioperative hypersensitivity. Clin Exp Allergy 2021; 52:334-344. [PMID: 34741356 DOI: 10.1111/cea.14040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 09/27/2021] [Accepted: 10/28/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Serum total tryptase has been shown to increase during acute allergic reactions (acute tryptase, TA ); however, few studies have investigated the values of TA or a combination of TA and baseline tryptase (TB ) 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 TA 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 TA and TB were included. Four formulas, including a change in TA >11 (F1), or >2+1.2xTB (F2), or >3+TB (F3), or >120%TB (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 TA 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 TA 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 TA for distinguishing positive from negative allergy testing suspected POH was 9.8 μg/L. TA value of 33 μg/L was required to achieve >90% PPV.
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Affiliation(s)
- Witchaya Srisuwatchari
- Department of Pulmonology, Division of Allergy, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Univ Montpellier, France.,Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | - Anna Borushko
- Department of Pulmonology, Division of Allergy, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Univ Montpellier, France.,Allergology and Occupational Pathology Course, Belarusian Medical Academy of Post-Graduate Education, Minsk, Belarus
| | - Simon Viville
- Department of Anesthesia and Intensive Care, Strasbourg University Hospital, Strasbourg, France
| | - Rodolphe Stenger
- Chest Diseases Department, Strasbourg University Hospital, Strasbourg, France
| | - Yoann Ehrhard
- Department of Pulmonology, Division of Allergy, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Univ Montpellier, France
| | - Jean-Marc Malinovsky
- Département d'Anesthésie-Réanimation, Centre Hospitalier Universitaire de Reims, Hopital Maison Blanche, Reims, France
| | - Paul-Michel Mertes
- Department of Anesthesia and Intensive Care, Strasbourg University Hospital, Strasbourg, France
| | - Pascal Demoly
- Department of Pulmonology, Division of Allergy, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Univ Montpellier, France.,UA11 Institute, Desbrest of Epidemiology and Public Health, INSERM, Univ Montpellier, Montpellier, France
| | - Anca-Mirela Chiriac
- Department of Pulmonology, Division of Allergy, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Univ Montpellier, France.,UA11 Institute, Desbrest of Epidemiology and Public Health, INSERM, Univ Montpellier, Montpellier, France
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10
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Gouel-Cheron A, Neukirch C, Kantor E, Malinovsky JM, Tacquard C, Montravers P, Mertes PM, Longrois D. Clinical reasoning in anaphylactic shock: addressing the challenges faced by anaesthesiologists in real time: A clinical review and management algorithms. Eur J Anaesthesiol 2021; 38:1158-1167. [PMID: 33973926 DOI: 10.1097/eja.0000000000001536] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Acute hypersensitivity reactions to drugs occur infrequently during anaesthesia and the peri-operative period. When clinical presentation includes the classical triad, erythema, cardiovascular abnormalities and increased airway pressure, the diagnosis is evident and the challenge is to prescribe a therapeutic regimen according to guidelines and to manage refractory signs in a timely manner. In many situations, however, the initial clinical signs are isolated, such as increased airway pressure or arterial hypotension. Rendering a differential diagnosis with causes and mechanisms other than acute hypersensitivity reactions (AHRs) is difficult, delaying treatment with possible worsening of the clinical signs, and even death, in previously healthy individuals. In these difficult diagnostic situations, clinical reasoning is mandatory, and guidelines do not explicitly explain the elements on which clinical reasoning can be built. In this article, based on clinical evidence whenever available, experimental data and pathophysiology, we propose algorithms that have been evaluated by experts. The goal of these algorithms is to provide explicit elements on which the differential diagnosis of AHRs can be made, accelerating the implementation of adequate therapy.
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Affiliation(s)
- Aurelie Gouel-Cheron
- From the Anaesthesiology and Critical Care Medicine Department, DMU PARABOL, Bichat Hospital, AP-HP (AGC, EK, PM, DL), Antibody in Therapy and Pathology, Pasteur Institute, UMR 1222 INSERM, Paris, France (AGC), Biostatistics Research Branch, Division of Clinical Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA (AGC), Pulmonology Department, Bichat Hospital, AP-HP, Paris University (CN), INSERM UMR 1152, Paris University, DHU FIRE, Paris (CN, PM), Anaesthesiology and Critical Care Medicine Department, Maison Blanche Hospital, Centre Hospitalier Universitaire de Reims, Reims (JM-M), Anaesthesiology and Critical Care Medicine Department, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg (CT, PM-M), Paris University (PM, DL), EA 3072, Institut de Physiologie, FMTS, Faculté de Médecine de Strasbourg, Université de Strasbourg, Strasbourg (PM-M) and INSERM1148, Paris, France (DL)
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11
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Thong BYH, Vultaggio A, Rerkpattanapipat T, Schrijvers R. Prevention of Drug Hypersensitivity Reactions: Prescreening and Premedication. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2958-2966. [PMID: 34366094 DOI: 10.1016/j.jaip.2021.04.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 04/03/2021] [Accepted: 04/07/2021] [Indexed: 01/08/2023]
Abstract
Drug hypersensitivity reactions (DHR) are heterogeneous in their pathomechanisms, clinical presentation, severity, and outcomes. Novel DHR mechanisms, phenotypes, and endotypes have been described. The key to prevention from further exposure to the culprit drugs involves correct identification of the putative drug through a combination of in vitro and/or in vivo tests, accurate drug allergy labeling and reporting, and electronic decision support systems within electronic medical records to prevent future accidental prescribing. Prescreening and premedication, the focus of this review, may be a useful adjunct to preventive measures in certain situations. After an index immediate drug hypersensitivity reaction, prescreening may be useful in perioperative anaphylaxis, and iodinated (ICM) and gadolinium-based contrast media (GCM) where the culprit and potential alternative agents are skin tested. In certain nonimmediate DHR, pharmacogenomic prescreening may be used before prescribing high-risk drugs (eg, carbamazepine and allopurinol) where specific human-leukocyte antigen genotypes are associated with severe cutaneous adverse reactions. Premedication with antihistamine and systemic corticosteroids is another therapeutic strategy to prevent infusion reactions for certain biologicals and chemotherapeutic agents, in cases of perioperative anaphylaxis, ICM and GCM DHR, and clonal mast cell disorders. Rapid drug desensitization may also be used to induce temporary tolerance in situations where there are limited alternative drugs.
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Affiliation(s)
- Bernard Yu-Hor Thong
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore.
| | - Alessandra Vultaggio
- Immunoallergology Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Ticha Rerkpattanapipat
- Allergy, Immunology and Rheumatology Division, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Rik Schrijvers
- Department of Microbiology, Immunology and Transplantation, Allergy and Clinical Immunology Research Group, KU Leuven, Leuven, Belgium
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12
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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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13
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Kalangara J, Vanijcharoenkarn K, Lynde GC, McIntosh N, Kuruvilla M. Approach to Perioperative Anaphylaxis in 2020: Updates in Diagnosis and Management. Curr Allergy Asthma Rep 2021; 21:4. [PMID: 33409706 DOI: 10.1007/s11882-020-00980-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2020] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW The goal of the paper is to review the epidemiology, pathogenesis, diagnosis, and manifestations of perioperative anaphylaxis (POA). We seek to review the most common culprits of POA and different diagnostic modalities for evaluation. RECENT FINDINGS Specific IgE testing has a limited role in POA evaluation due to lack of widespread availability and low sensitivity. Basophil activation testing is complementary to skin tests and can assist NMBA sensitivity diagnosis in complex cases. In the past years, there has been an exponential increase in suspected teicoplanin allergic reactions in the European Union. Chlorhexidine is also being increasingly implicated as a culprit in POA. Multiple classes of perioperative medications cause POA. Diagnostic modalities available include skin testing with nonirritating concentrations, basophil activation tests, specific IgE, and drug provocation testing. An accurate record and critical analysis of perioperative events is more important than isolated test results. Future studies evaluating the pathophysiology of these reactions and other therapeutic strategies, such as targeting the MRGPRX2 receptor, are needed.
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Affiliation(s)
- Jerry Kalangara
- Division of Pain Medicine, Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA
- Atlanta VA Health Care System, Decatur, GA, USA
| | - Kristine Vanijcharoenkarn
- Division of Pulmonary, Allergy and Critical Care, Emory University School of Medicine, Atlanta, GA, USA
| | - Grant C Lynde
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Nichole McIntosh
- Atlanta VA Health Care System, Decatur, GA, USA
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Merin Kuruvilla
- Division of Pulmonary, Allergy and Critical Care, Emory University School of Medicine, Atlanta, GA, USA.
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14
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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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Spindola MAC, Solé D, Aun MV, Azi LMTDA, Bernd LAG, Garcia DB, Capelo AV, Cumino DDO, Lacerda AE, Lima LC, Morato EF, Nunes RR, Rubini NDPM, da Silva J, Tardelli MÂ, Watanabe AS, Curi EF, Sano F. [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]. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2020; 70:534-548. [PMID: 33077175 PMCID: PMC9373446 DOI: 10.1016/j.bjan.2020.06.004] [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: 12/02/2019] [Revised: 04/17/2020] [Accepted: 06/20/2020] [Indexed: 11/20/2022]
Abstract
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.
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Affiliation(s)
- Maria Anita Costa Spindola
- Universidade Federal de Santa Catarina, Hospital Universitário Professor Polydoro Ernani de São Thiago, Florianópolis, SC, Brazil; Sociedade Brasileira de Anestesiologia, Brazil
| | - Dirceu Solé
- Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo, SP, Brazil; Associação Brasileira de Alergia e Imunologia, Brazil
| | - Marcelo Vivolo Aun
- Associação Brasileira de Alergia e Imunologia, Brazil; Faculdade Israelita de Ciências da Saúde Albert Eisntein, 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, Brazil; Universidade Federal da Bahia, Hospital Universitário Professor Edgard Santos, Salvador, BA, Brazil.
| | - Luiz Antonio Guerra Bernd
- Associação Brasileira de Alergia e Imunologia, Brazil; Fundação Faculdade Federal de Ciências Médicas de Porto Alegre, Porto Alegre, RS, Brasil
| | - Daniela Bianchi Garcia
- Sociedade Brasileira de Anestesiologia, Brazil; Hospital Infantil Pequeno Príncipe, Curitiba, PR, Brazil
| | - Albertina Varandas Capelo
- Associação Brasileira de Alergia e Imunologia, Brazil; Universidade Federal do Rio de Janeiro, Hospital Universitário Gaffrée e Guinle, Rio de Janeiro, RJ, Brazil
| | | | - Alex Eustáquio Lacerda
- Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo, SP, Brazil; Associação Brasileira de Alergia e Imunologia, Brazil
| | - Luciana Cavalcanti Lima
- Associação Brasileira de Alergia e Imunologia, Brazil; Instituto Medicina Integral Professor 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, Brazil; Hospital Geral de Fortaleza (HGF), Departamento de Anestesia, Fortaleza, CE, Brazil
| | - Norma de Paula Motta Rubini
- Associação Brasileira de Alergia e Imunologia, Brazil; Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Jane da Silva
- Universidade Federal de Santa Catarina, Hospital Universitário Professor Polydoro Ernani de São Thiago, Florianópolis, SC, Brazil; Sociedade Brasileira de Anestesiologia, Brazil
| | - Maria Ângela Tardelli
- Sociedade Brasileira de Anestesiologia, Brazil; Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo, SP, Brazil
| | - Alexandra Sayuri Watanabe
- Associação Brasileira de Alergia e Imunologia, Brazil; Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, São Paulo, SP, Brazil
| | - Erick Freitas Curi
- Sociedade Brasileira de Anestesiologia, Brazil; Universidade Federal do Espírito Santo, Vitória, ES, Brazil
| | - Flávio Sano
- Associação Brasileira de Alergia e Imunologia, Brazil; Hospital Nipo Brasileiro, São Paulo, SP, Brazil
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Spindola MAC, Solé D, Aun MV, Azi LMTDA, Bernd LAG, Garcia DB, Capelo AV, Cumino DDO, Lacerda AE, Lima LC, Morato EF, Nunes RR, Rubini NDPM, da Silva J, Tardelli MÂ, Watanabe AS, Curi EF, Sano F. 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. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2020. [PMID: 33077175 PMCID: PMC9373446 DOI: 10.1016/j.bjane.2020.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Maria Anita Costa Spindola
- Universidade Federal de Santa Catarina, Hospital Universitário Professor Polydoro Ernani de São Thiago, Florianópolis, SC, Brazil; Sociedade Brasileira de Anestesiologia, Brazil
| | - Dirceu Solé
- Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo, SP, Brazil; Associação Brasileira de Alergia e Imunologia, Brazil
| | - Marcelo Vivolo Aun
- Associação Brasileira de Alergia e Imunologia, Brazil; Faculdade Israelita de Ciências da Saúde Albert Eisntein, 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, Brazil; Universidade Federal da Bahia, Hospital Universitário Professor Edgard Santos, Salvador, BA, Brazil.
| | - Luiz Antonio Guerra Bernd
- Associação Brasileira de Alergia e Imunologia, Brazil; Fundação Faculdade Federal de Ciências Médicas de Porto Alegre, Porto Alegre, RS, Brasil
| | - Daniela Bianchi Garcia
- Sociedade Brasileira de Anestesiologia, Brazil; Hospital Infantil Pequeno Príncipe, Curitiba, PR, Brazil
| | - Albertina Varandas Capelo
- Associação Brasileira de Alergia e Imunologia, Brazil; Universidade Federal do Rio de Janeiro, Hospital Universitário Gaffrée e Guinle, Rio de Janeiro, RJ, Brazil
| | | | - Alex Eustáquio Lacerda
- Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo, SP, Brazil; Associação Brasileira de Alergia e Imunologia, Brazil
| | - Luciana Cavalcanti Lima
- Associação Brasileira de Alergia e Imunologia, Brazil; Instituto Medicina Integral Professor 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, Brazil; Hospital Geral de Fortaleza (HGF), Departamento de Anestesia, Fortaleza, CE, Brazil
| | - Norma de Paula Motta Rubini
- Associação Brasileira de Alergia e Imunologia, Brazil; Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Jane da Silva
- Universidade Federal de Santa Catarina, Hospital Universitário Professor Polydoro Ernani de São Thiago, Florianópolis, SC, Brazil; Sociedade Brasileira de Anestesiologia, Brazil
| | - Maria Ângela Tardelli
- Sociedade Brasileira de Anestesiologia, Brazil; Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo, SP, Brazil
| | - Alexandra Sayuri Watanabe
- Associação Brasileira de Alergia e Imunologia, Brazil; Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, São Paulo, SP, Brazil
| | - Erick Freitas Curi
- Sociedade Brasileira de Anestesiologia, Brazil; Universidade Federal do Espírito Santo, Vitória, ES, Brazil
| | - Flávio Sano
- Associação Brasileira de Alergia e Imunologia, Brazil; Hospital Nipo Brasileiro, São Paulo, SP, Brazil
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Grade IV perioperative anaphylaxis to atracurium despite a previous negative skin test. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:2445-2447. [DOI: 10.1016/j.jaip.2020.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Revised: 03/20/2020] [Accepted: 04/01/2020] [Indexed: 12/15/2022]
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Skin Testing to Identify Safe Drugs for Patients with Rocuronium-Induced Anaphylaxis. Case Rep Anesthesiol 2020; 2020:8163620. [PMID: 32082637 PMCID: PMC7008275 DOI: 10.1155/2020/8163620] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 12/30/2019] [Indexed: 01/14/2023] Open
Abstract
Among patients who develop anaphylaxis during anesthesia, anaphylaxis caused by a neuromuscular blocking agent has the highest incidence. In patients who developed IgE-mediated anaphylaxis, and cross-reactivity among NMBAs is a concern in subsequent anesthetic procedures. We present a patient who developed rocuronium-induced anaphylaxis in whom the skin prick test (SPT) and intradermal test (IDT) could identify a safe drug to use in the subsequent anesthetic procedure. A 32-year-old female developed anaphylactic shock at the induction of general anesthesia. She recovered by administration of hydrocortisone and epinephrine. Skin tests including the SPT followed by the IDT revealed rocuronium as the drug that caused anaphylaxis and vecuronium as a safe drug to use for the subsequent general anesthesia. She safely underwent surgery with general anesthesia using vecuronium one month after the skin testing. There are not many reports on the effectiveness of the SPT followed by IDT in identifying the causative drug as well as a safe drug to use in the subsequent anesthetic procedure following anaphylaxis during anesthesia. The usefulness of the SPT should be re-evaluated.
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Garvey LH, Ebo DG, Mertes P, Dewachter P, Garcez T, Kopac P, Laguna JJ, Chiriac AM, Terreehorst I, Voltolini S, Scherer K. An EAACI position paper on the investigation of perioperative immediate hypersensitivity reactions. Allergy 2019; 74:1872-1884. [PMID: 30964555 DOI: 10.1111/all.13820] [Citation(s) in RCA: 114] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Accepted: 03/19/2019] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Lene Heise Garvey
- Danish Anaesthesia Allergy Centre, Allergy Clinic, Department of Dermatology and Allergy Copenhagen University Hospital Gentofte Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
| | - Didier G. Ebo
- Faculty of Medicine and Health Science, Department of Immunology – Allergology – Rheumatology Antwerp University Hospital, University of Antwerp Antwerp Belgium
| | - Paul‐Michel Mertes
- Department of Anesthesia and Intensive Care Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, EA 3072, FMTS de Strasbourg Strasbourg France
| | - Pascale Dewachter
- Service d’Anesthésie‐Réanimation, Groupe Hospitalier de Paris‐Seine‐Saint‐Denis Assistance Publique‐Hôpitaux de Paris & Université Paris 13, Sorbonne Paris Cité Paris France
| | - Tomaz Garcez
- Immunology Department Manchester University NHS Foundation Trust Manchester UK
| | - Peter Kopac
- University Clinic of Respiratory and Allergic Diseases Golnik Slovenia
| | - José Julio Laguna
- Allergy Unit, Allergo‐Anaesthesia Unit, Faculty of Medicine Hospital Central de la Cruz Roja, Alfonso X El Sabio University, ARADyAL Madrid Spain
| | - Anca Mirela Chiriac
- Allergy Unit, Département de Pneumologie et Addictologie, Hôpital Arnaud de Villeneuve University Hospital of Montpellier Montpellier France
- Sorbonnes Universités, UPMC Paris 06, UMR‐S 1136, IPLESP, Equipe EPAR Paris France
| | - Ingrid Terreehorst
- Department of ENT and DPAC AUMCAmsterdam University Medical Center Amsterdam The Netherlands
| | | | - Kathrin Scherer
- Allergy Unit, Department of Dermatology, University Hospital University of Basel Basel Switzerland
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Ebo DG, Van Gasse AL, Decuyper II, Uyttebroek A, Sermeus LA, Elst J, Bridts CH, Mertens CM, Faber MA, Hagendorens MM, De Clerck LS, Sabato V. Acute Management, Diagnosis, and Follow-Up of Suspected Perioperative Hypersensitivity Reactions in Flanders 2001-2018. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:2194-2204.e7. [DOI: 10.1016/j.jaip.2019.02.031] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 01/25/2019] [Accepted: 02/15/2019] [Indexed: 12/20/2022]
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Volcheck GW, Hepner DL. Identification and Management of Perioperative Anaphylaxis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:2134-2142. [DOI: 10.1016/j.jaip.2019.05.033] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 05/15/2019] [Accepted: 05/17/2019] [Indexed: 01/07/2023]
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23
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Garvey LH, Dewachter P, Hepner DL, Mertes PM, Voltolini S, Clarke R, Cooke P, Garcez T, Guttormsen AB, Ebo DG, Hopkins PM, Khan DA, Kopac P, Krøigaard M, Laguna JJ, Marshall S, Platt P, Rose M, Sabato V, Sadleir P, Savic L, Savic S, Scherer K, Takazawa T, Volcheck GW, Kolawole H. Management of suspected immediate perioperative allergic reactions: an international overview and consensus recommendations. Br J Anaesth 2019; 123:e50-e64. [DOI: 10.1016/j.bja.2019.04.044] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 04/04/2019] [Accepted: 04/14/2019] [Indexed: 12/11/2022] Open
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Misbah SA, Krishna MT. Peri-Operative Anaphylaxis-An Investigational Challenge. Front Immunol 2019; 10:1117. [PMID: 31191519 PMCID: PMC6549036 DOI: 10.3389/fimmu.2019.01117] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 05/02/2019] [Indexed: 12/12/2022] Open
Abstract
Patients with suspected peri-operative anaphylaxis (POP) require thorough investigation to identify underlying trigger(s) and enable safe anesthesia for subsequent surgery. The changing epidemiology of POP has been striking. Previous estimates of the incidence of POP have ranged between 1:6,000 and1:20,000 anesthetics, but more recent data from France and the United Kingdom suggest an estimated incidence of 1:10,000. Other important changes include a change in the hierarchy of well-recognized triggers, with antibiotics (beta-lactams) supplanting neuromuscular blockers (NMB) as the leading cause of POP. The emergence of chlorhexidine, patent blue dye, and teicoplanin as important triggers have also been noteworthy findings. The mainstay of investigation revolves around critical analysis of the time-line of events leading up to anaphylaxis coupled with judicious skin testing. Skin tests have limitations with respect to unknown predictive values for most drugs/agents and therefore, knowledge of background positivity in healthy controls, test characteristics of individual drugs and the use of non-irritant concentrations is essential to avoid both false-positive and false-negative results. Specific IgE assays for individual drugs are available only for a limited number of agents and are not a substitute for skin testing. Acute serum total tryptase has a high specificity and positive predictive value in IgE-mediated POP anaphylaxis but is limited by its moderate sensitivity and negative predictive value. Planning for safe anesthesia in this group of patients is particularly challenging and consequently anesthetists need to be alert to the possibility of repeat episodes of anaphylaxis. Because of the limitations of current investigations for POP, collecting systematic data on the outcome of repeat anesthesia is valuable in validating current investigatory approaches. This paper reviews the changing epidemiology of POP with reference to the main triggers, and the investigation and outcome of subsequent anesthesia.
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Affiliation(s)
- Siraj A Misbah
- Department of Clinical Immunology, Oxford University Foundation Hospitals NHS Trust, Oxford, United Kingdom
| | - Mamidipudi Thirumala Krishna
- Department of Allergy and Immunology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom.,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
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Li J, Best OG, Rose MA, Green SL, Fulton RB, Capon MJ, Krupowicz BA, Fernando SL. Assessing cross-reactivity to neuromuscular blocking agents by skin and basophil activation tests in patients with neuromuscular blocking agent anaphylaxis. Br J Anaesth 2019; 123:e144-e150. [PMID: 30961915 DOI: 10.1016/j.bja.2019.03.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 02/20/2019] [Accepted: 03/01/2019] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Following diagnosis of neuromuscular blocking agent (NMBA) anaphylaxis, identifying safe alternatives for subsequent anaesthesia is critical. A patient with anaphylaxis to one NMBA can also have an allergic reaction to other NMBAs (cross-reactivity). Whilst drug provocation testing is standard for identifying or excluding allergy, there is significant risk. In vitro, after an allergen activates basophils, basophils express surface activation markers that can be measured by basophil activation testing (BAT). We compared cross-reactivity between NMBAs assessed by BAT against that by skin testing. METHODS All patients attending an anaesthetic allergy clinic in Sydney, Australia between May 2017 and July 2018 diagnosed with NMBA anaphylaxis qualified for this study comparing intradermal skin tests and BAT with a panel of NMBAs (rocuronium, vecuronium, pancuronium, suxamethonium, cisatracurium). RESULTS Of the 61 patients participating, sensitisation on skin testing and on BAT completely matched in only nine patients (15%). Sensitisation was not in agreement for pancuronium, cisatracurium and rocuronium, but was in agreement for vecuronium and suxamethonium. Nine patients with negative skin tests subsequently tolerated cisatracurium, and one false positive on BAT to cisatracurium was detected. CONCLUSIONS The utility of BAT in identifying safe NMBAs for subsequent anaesthesia needs further evaluation. BAT detects a different cross-reactivity profile to skin tests. Negative skin testing and BAT might increase confidence in performing drug provocation testing, but this and follow-up of subsequent anaesthesia in our cohort is necessary to determine the clinical significance of BAT sensitisation.
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Affiliation(s)
- Jamma Li
- Department of Clinical Immunology and Allergy, Australia; Medicine (Immunology & Infectious Diseases), University of Sydney, Sydney, Australia; NSW Health Pathology, Sydney, Australia.
| | - Oliver G Best
- Medicine (Immunology & Infectious Diseases), University of Sydney, Sydney, Australia
| | - Michael A Rose
- Department of Anaesthesia, Royal North Shore Hospital, Sydney, Australia
| | - Sarah L Green
- Department of Anaesthesia, Royal North Shore Hospital, Sydney, Australia
| | | | - Marc J Capon
- Department of Anaesthesia, Royal North Shore Hospital, Sydney, Australia
| | | | - Suran L Fernando
- Department of Clinical Immunology and Allergy, Australia; Medicine (Immunology & Infectious Diseases), University of Sydney, Sydney, Australia; NSW Health Pathology, Sydney, Australia
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Anaesthetic management of patients with pre-existing allergic conditions: a narrative review. Br J Anaesth 2019; 123:e65-e81. [PMID: 30916009 DOI: 10.1016/j.bja.2019.01.020] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 01/12/2019] [Accepted: 01/22/2019] [Indexed: 12/18/2022] Open
Abstract
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.
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27
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Comparative epidemiology of suspected perioperative hypersensitivity reactions. Br J Anaesth 2019; 123:e16-e28. [PMID: 30916015 DOI: 10.1016/j.bja.2019.01.027] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 12/24/2018] [Accepted: 01/15/2019] [Indexed: 12/31/2022] Open
Abstract
Suspected perioperative hypersensitivity reactions are rare but contribute significantly to the morbidity and mortality of surgical procedures. Recent publications have highlighted the differences between countries concerning the respective risk of different drugs, and changes in patterns of causal agents and the emergence of new allergens. This review summarises recent information on the epidemiology of perioperative hypersensitivity reactions, with specific consideration of differences between geographic areas for the most frequently involved offending agents.
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28
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Perioperative anaphylaxis-management and outcomes in NAP6. Br J Anaesth 2018; 121:120-123. [PMID: 29935563 DOI: 10.1016/j.bja.2018.05.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 05/09/2018] [Indexed: 01/09/2023] Open
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