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Mak HW, Au EY, Yeung MH, Chiang V, Lam K, Wong JC, Yeung HH, Chan EY, Lau CS, Li PH. Extending the role of tryptase in perioperative anaphylaxis: Predicting positive results in basophil activation tests. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. GLOBAL 2024; 3:100297. [PMID: 39176077 PMCID: PMC11339248 DOI: 10.1016/j.jacig.2024.100297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 04/02/2024] [Accepted: 04/05/2024] [Indexed: 08/24/2024]
Abstract
Background Basophil activation tests (BATs) are useful in identifying culprits of perioperative anaphylaxis (PA), but their utility remains limited due to technical limitations, cost, and availability. Being able to prioritize patients with likely higher yields for BAT would be useful in reducing costs and manpower. Objective We sought to investigate whether tryptase levels and clinical parameters may be useful for selecting patients for BATs. Methods We performed a 10-year retrospective study in Hong Kong to investigate the performance of BATs associated with tryptase levels (taking during PA) and other clinical parameters. Results Of 90 patients, 70 (77.8%) showed significant tryptase level elevation and 37 (41.1%) had a positive BAT result. BAT-positive patients presented with significantly higher absolute levels (15.9 μg/L vs 9.1 μg/L; P = .018), absolute elevation (12.8 μg/L vs 7.1 μg/L; P = .012), and fold elevation (5.6- vs 4.1-fold; P = .014) of acute tryptase than did BAT-negative patients. Among patients with positive BAT result, 94.6% (35 of 37) demonstrated elevated acute tryptase, significantly more than the BAT-negative group (66.0%; P < .001). In regression analysis, tryptase elevation was the sole significant factor correlated to BAT positivity (odds ratio, 10.14; 95% CI, 2.15-47.85; P = .003). Overall, elevated acute tryptase demonstrated a sensitivity of 94.7% and a negative predictive value of 90.0% in predicting positive results with BATs. Conclusions We observed that tryptase elevation is a very sensitive predictor of BAT positivity among patients with identified culprits of PA. Acute elevation of tryptase would not only aid in confirming anaphylaxis but may also help guide the decision toward selecting labor-intensive and costly in vitro tests such as BATs.
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Affiliation(s)
- Hugo W.F. Mak
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, Hong Kong
| | - Elaine Y.L. Au
- Division of Clinical Immunology, Department of Pathology, Queen Mary Hospital, Hong Kong
| | - Maegan H.Y. Yeung
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, Hong Kong
| | - Valerie Chiang
- Division of Clinical Immunology, Department of Pathology, Queen Mary Hospital, Hong Kong
| | - Ki Lam
- Division of Clinical Immunology, Department of Pathology, Queen Mary Hospital, Hong Kong
| | - Jane C.Y. Wong
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, Hong Kong
| | - Heather H.F. Yeung
- Division of Clinical Immunology, Department of Pathology, Queen Mary Hospital, Hong Kong
| | - Eric Y.T. Chan
- Division of Clinical Immunology, Department of Pathology, Queen Mary Hospital, Hong Kong
| | - Chak-sing Lau
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, Hong Kong
| | - Philip H. Li
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, Hong Kong
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Manlapaz M, Farag E. Breaking the stigma: Safe use of Cefazolin in perioperative patients with penicillin allergy label. J Clin Anesth 2024; 97:111541. [PMID: 38944593 DOI: 10.1016/j.jclinane.2024.111541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 06/13/2024] [Accepted: 06/23/2024] [Indexed: 07/01/2024]
Affiliation(s)
- Mariel Manlapaz
- Department of Multispecialty Anesthesiology, Cleveland Clinic, Cleveland, OH 44124, United States of America.
| | - Ehab Farag
- Department of Multispecialty Anesthesiology, Cleveland Clinic, Cleveland, OH 44124, United States of America
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Lim Zee ZJ, Karalapillai D, Kolawole H, Fiddes C, Pilcher D, Subramaniam A. A retrospective registry-based study into the proportion of patients admitted to intensive care who have anaphylaxis as a principal diagnosis and their outcomes in Australia and New Zealand. CRIT CARE RESUSC 2024; 26:185-191. [PMID: 39355504 PMCID: PMC11440054 DOI: 10.1016/j.ccrj.2024.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 06/07/2024] [Accepted: 06/12/2024] [Indexed: 10/03/2024]
Abstract
Objective To describe the proportion of patients admitted to intensive care who have anaphylaxis as a principal diagnosis and their subsequent outcomes in Australia and New Zealand. Design Retrospective observational study of ICU admissions for severe anaphylaxis. Setting ICU admissions recorded in the Australian and New Zealand Intensive Care Society Adult Patient Database between 2012 and 2022. Participants Adults 16 years or older with severe anaphylaxis admitted to the ICU. Interventions None. Main outcome measures Proportion of patients admitted to ICU who have anaphylaxis as a principal diagnosis, mortality rate, ICU and hospital length of stay. Results 7189 of the 7270 ICU admissions for severe anaphylaxis recorded between 2012 and 2022, were included in the analysis. This represented a proportion from 0.25% in 2012 to 0.43% in 2022. ICU and hospital mortality were 0.4% and 0.8%, respectively. The proportion of ICUs reporting at least one severe anaphylaxis each year increased from 61.7% in 2012 to 83.0% in 2022. Most of the patients were discharged home (92.6%, n = 6660). Increasing age (OR = 1.055; 95%CI: 1.008-1.105) and SOFA scores (OR = 1.616; 95%CI: 1.265-2.065), an immunosuppressive chronic condition (OR = 16.572; 95%CI: 3.006-91.349) and an increasing respiratory rate above 16 breaths/min (OR = 1.116; 95%CI: 1.057-1.178) predicted in-hospital mortality in patients with anaphylaxis, while higher GCS decreased in-hospital mortality (OR = 0.827; 95%CI: 0.705-0.969). Conclusions The overall proportion of patients admitted to ICU who have anaphylaxis as a principal diagnosis has increased. In-hospital mortality remains low despite the need for vital organ support. Further studies should investigate these identified factors that may predict in-hospital mortality among these patients. Trial registration Not applicable.
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Affiliation(s)
- Zheng Jie Lim Zee
- Department of Anaesthesia, Austin Hospital, Heidelberg, Victoria, Australia
- Department of Anaesthesia and Pain Medicine, Northern Health, Epping, Victoria, Australia
| | - Dharshi Karalapillai
- Department of Anaesthesia, Austin Hospital, Heidelberg, Victoria, Australia
- Department of Intensive Care, Austin Hospital, Heidelberg, Victoria, Australia
- Department of Critical Care, University of Melbourne, Parkville, Victoria, Australia
| | - Helen Kolawole
- Department of Anaesthesia, Peninsula Health, Frankston, Victoria, Australia
- Department of Anaesthesia Teaching and Research, Monash University, Melbourne, Victoria, Australia
| | - Chris Fiddes
- Department of Anaesthesia, Austin Hospital, Heidelberg, Victoria, Australia
| | - David Pilcher
- Department of Intensive Care, Alfred Hospital, Melbourne, Victoria, Australia
- Centre for Outcome and Resource Evaluation, Australian and New Zealand Intensive Care Society, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ashwin Subramaniam
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care, Peninsula Health, Frankston, Victoria, Australia
- Department of Intensive Care, Dandenong Hospital, Monash Health, Dandenong, Victoria, Australia
- Peninsula Clinical School, Monash University, Frankston, Victoria, Australia
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Youssef MR, Martinez E, Pinnock TM, Gonzalez-Estrada A, Smith MM, Smith BB. Assessment of Perioperative Protamine Reactions in Patients With Fish Allergies: A Retrospective Observational Study. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00542-1. [PMID: 39261207 DOI: 10.1053/j.jvca.2024.08.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2024] [Revised: 08/10/2024] [Accepted: 08/16/2024] [Indexed: 09/13/2024]
Abstract
OBJECTIVES To retrospectively assess the incidence and severity of perioperative protamine reactions in adult patients with documented history of fish allergy. DESIGN Retrospective observational study. SETTING Large academic tertiary referral center. PARTICIPANTS Adults with fish allergies undergoing surgeries involving protamine, between January 1, 2008, and March 1, 2018. INTERVENTIONS Perioperative protamine administration in patients with documented fish allergy. MEASUREMENTS AND MAIN RESULTS Perioperative protamine and anaphylactic reactions were reviewed. A diagnosis of anaphylaxis or protamine reaction was based on clinical suspicion, perioperative events, and postoperative evaluations. Among 214 patients, 2 cases (<1%) of anaphylaxis or protamine reactions occurred. Cardiac procedures were most common (67%). The median intraoperative heparin dosage was 46,000 IU, and the median protamine dosage was 310 mg. Nearly all patients (99%) were admitted to the intensive care unit postoperatively, with a median hospital stay of 6.5 days (interquartile range, 5.2-14.6 days). There were 3 deaths (1%) within 30 days, and 15 (7%) within 1 year. CONCLUSIONS The study findings suggest that in patients with a history of fish allergy, cross-reactivity with protamine is unlikely, as anaphylaxis and/or protamine reactions were rare in this patient population in the perioperative environment. Based on these findings, this study does not recommend avoiding protamine solely based on a history of fish allergy when heparin reversal is required during surgery.
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Affiliation(s)
- Mohanad R Youssef
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, AZ
| | - Eryberto Martinez
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, AZ
| | - Terrique M Pinnock
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
| | - Alexei Gonzalez-Estrada
- Division of Allergy, Asthma and Clinical Immunology, Department of Medicine, Mayo Clinic, Phoenix, AZ
| | - Mark M Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Bradford B Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, AZ.
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Littlejohns A, Savic L. Management and treatment of perioperative hypersensitivity. Curr Opin Allergy Clin Immunol 2024; 24:210-217. [PMID: 38814699 DOI: 10.1097/aci.0000000000001000] [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: 05/31/2024]
Abstract
PURPOSE OF REVIEW Perioperative hypersensitivity reactions are rare but potentially catastrophic events. This review acts to summarize recent recommendations for both immediate and poststabilization management of suspected reactions, alongside practical advice for anaesthetists who may be faced with these events. RECENT FINDINGS Prompt treatment is essential but may be hampered by delay in recognition. This can occur because there are multiple differential diagnoses for the observed clinical signs as well as variations in clinical presentation. Resuscitation is dependent on the use of adrenaline and fluids. Adrenaline should be administered in small, titrated intravenous boluses. Low-dose infusions should be commenced early if the response to boluses is poor. Large volume fluid resuscitation may be required to maintain adequate circulating volume. Chest compressions are recommended when there is evidence of inadequate perfusion, rather than waiting until cardiac arrest is confirmed. Antihistamines and corticosteroids are no longer recommended in the immediate management phase. Once the patient has been stabilized, it is important to obtain serial tryptase concentrations to aid the subsequent clinic investigation. The decision to proceed or abandon surgery will be based on an individual risk-benefit analysis. All cases of suspected perioperative hypersensitivity, including fatal cases, must be referred for formal investigation. SUMMARY There have been recent updates to management guidelines in perioperative hypersensitivity. Treatment algorithms, treatment packs and referral packs can all help the anaesthetist manage these complex cases, aid the subsequent investigation and ensure patient safety in the future.
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Affiliation(s)
- Anna Littlejohns
- Anaesthetic Department, Leeds Teaching Hospitals Trust, Leeds, UK
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Kinjo R, Kojima T, Miyamoto T, Sakaguchi T, Suzuki R. A Case of Anaphylactic Shock Suspected to Be Caused by Bovine Serum Albumin Tissue Adhesive (BioGlue) During Thoracoabdominal Aortic Replacement. Cureus 2024; 16:e62678. [PMID: 39036193 PMCID: PMC11258937 DOI: 10.7759/cureus.62678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2024] [Indexed: 07/23/2024] Open
Abstract
Bovine serum albumin (BSA) tissue adhesive (BioGlue, Cryolife Inc., Kennesaw, GA, USA) is often used as a hemostatic adjunct in adult patients undergoing open surgical repair of large vessels, such as the aorta, femoral, and carotid arteries. We present a case of intraoperative anaphylaxis attributed to the use of BioGlue during thoracoabdominal aortic replacement. The patient suddenly developed hypotension, hypoxemia, and airway edema after the BioGlue application. BioGlue is composed of purified BSA and glutaraldehyde. Despite the BSA component being an allergen that can cause anaphylaxis in some patients, reported occurrences of anaphylaxis are extremely rare. We need to recognize BSA tissue adhesive as a potential allergen. In the event of an intraoperative shock, prompt recognition and investigation of the underlying cause are necessary.
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Affiliation(s)
- Rintaro Kinjo
- Cardiovascular Surgery, Japanese Red Cross Kumamoto Hospital, Kumamoto, JPN
| | - Takenori Kojima
- Cardiovascular Surgery, Japanese Red Cross Kumamoto Hospital, Kumamoto, JPN
| | - Tomoya Miyamoto
- Cardiovascular Surgery, Japanese Red Cross Kumamoto Hospital, Kumamoto, JPN
| | - Takeshi Sakaguchi
- Cardiovascular Surgery, Japanese Red Cross Kumamoto Hospital, Kumamoto, JPN
| | - Ryusuke Suzuki
- Cardiovascular Surgery, Japanese Red Cross Kumamoto Hospital, Kumamoto, JPN
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Gonzalez-Estrada A, Carrillo-Martin I, Morgenstern-Kaplan D, Rukasin CRF, Rank MA, Park MA, Yee CI, Volcheck GW. A US-Based Multicenter Retrospective Report of Perioperative Anaphylaxis, 2010-2021. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:1594-1602.e9. [PMID: 38580206 DOI: 10.1016/j.jaip.2024.02.042] [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: 01/13/2023] [Revised: 01/18/2024] [Accepted: 02/17/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND US-based perioperative anaphylaxis (POA) studies are limited to single-center experiences. A recent report found that a serum acute tryptase (sAT) >9.8 ng/mL or mast cell activation (MCA) can predict POA causal agent identification. Urinary mast cell mediator metabolites (uMC) have not been studied in POA. OBJECTIVE To analyze the epidemiologic data of POA, to determine if sAT or MCA can predict suspected causal agent identification, and to evaluate uMC utility in POA. METHODS This study is a retrospective multicenter review of POA cases that were subcategorized by suspected causal agent identification status. sAT, MCA (defined as sAT >2 + 1.2 × serum baseline tryptase), and uMC (N-methylhistamine [N-MH], 11β-prostaglandin-F2α [11β-PGF2α], leukotriene E4 [LTE4]) were recorded. RESULTS Of 100 patients (mean age 52 [standard deviation 17] years, 94% adult, 50% female, 90% White, and 2% Hispanic) with POA, 73% had an sAT available, 41% had MCA, 16% had uMC available, and 50% had an identifiable suspected cause. POA cases with an identifiable suspected cause had a positive MCA status (100% vs 78%; P = .01) compared with POA with an unidentifiable cause. An elevated median sAT did not predict causal agent identification. Positive uMC were not associated with suspected causal agent identification during POA. Patients with positive uMC had a higher median sAT (30 vs 6.45 ng/mL; P = .001) and MCA status (96% vs 12%; P = .001) compared with negative uMC patients. Patients with POA had an elevated acute/baseline uMC ratios: 11β-PGF2α ratio > 1.6, N-MH ratio >1.7, and LTE4 ratio >1.8. CONCLUSIONS The presence of MCA in POA is associated with suspected causal agent identification. Positive uMC possibly correlate with a higher sAT level and MCA status but require further study. The authors suggest applying an acute/baseline uMC ratio (11β-PGF2α ratio >1.6, N-MH ratio >1.7, and LTE4 ratio >1.87) in patients with POA for MCA when a tryptase level is inconclusive during POA evaluations.
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Affiliation(s)
- Alexei Gonzalez-Estrada
- Division of Pulmonary, Allergy and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Fla.
| | - Ismael Carrillo-Martin
- Division of Pulmonary, Allergy and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Fla
| | - Dan Morgenstern-Kaplan
- Division of Pulmonary, Allergy and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Fla
| | - Christine R F Rukasin
- Division of Allergy, Asthma and Clinical Immunology, Department of Medicine, Mayo Clinic, Scottsdale, Ariz; Division of Pulmonary, Section of Allergy/Immunology, Phoenix Children's Hospital, Phoenix, Ariz
| | - Matthew A Rank
- Division of Allergy, Asthma and Clinical Immunology, Department of Medicine, Mayo Clinic, Scottsdale, Ariz; Division of Pulmonary, Section of Allergy/Immunology, Phoenix Children's Hospital, Phoenix, Ariz
| | - Miguel A Park
- Division of Allergic Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minn
| | - Claire I Yee
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Scottsdale, Ariz
| | - Gerald W Volcheck
- Division of Allergic Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minn
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Dewachter P, Mouton-Faivre C, Dimby SF, Vicaut E, Beloucif S. Association Between Early Patient Characteristics and IgE-Mediated Allergy in the Perioperative Setting. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:1202-1214.e3. [PMID: 38378094 DOI: 10.1016/j.jaip.2024.02.009] [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: 10/09/2023] [Revised: 01/24/2024] [Accepted: 02/08/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND Early recognition of perioperative anaphylaxis, a life-threatening, usually IgE-mediated, immediate hypersensitivity, is essential, but bedside diagnosis is not always straightforward because clinical presentation may vary. OBJECTIVES To describe early characteristics of perioperative immediate hypersensitivity, with special attention to cutaneous phenotypes, and identify risk factors for IgE-mediated allergy. METHODS We retrospectively analyzed data from adults with suspected perioperative immediate hypersensitivity who were investigated in two academic medical centers. Multivariable logistic regression was conducted to evaluate associations among patient, clinical, and paraclinical characteristics and IgE-mediated allergy. RESULTS Of 145 enrolled patients, 99 (68.3%) and 46 (31.7%) were respectively categorized in the IgE-mediated allergy and non-allergy groups. Cutaneous vasoconstriction phenotype (pallor, piloerection, thelerethism, and sweating with or without cyanosis) occurring within minutes (or even 1 minute) of drug exposure was strongly associated with IgE-mediated allergy (adjusted odds ratio [aOR] = 28.02; 95% CI, 4.41-305.18). IgE-mediated allergy was always life-threatening in this setting. Other early factors associated with allergy were low end-tidal carbon dioxide 25 mm Hg or less (aOR = 5.45; 95% CI, 2.39-26.45), low mean arterial pressure 60 mm Hg or less (aOR = 3.82; 95% CI, 1.28-17.31), and early cutaneous vasodilation (erythema, urticaria, and/or angioedema) (aOR = 2.78; 95% CI, 0.73-20.54). Late cutaneous vasodilation after restoration of hemodynamics corroborated the diagnosis of allergy (aOR = 23.67; 95% CI, 4.94-205.09). The best-fit model including three readily available variables (cutaneous phenotype involving the three modalities [reference lack of cutaneous signs], low mean arterial pressure, and low end-tidal carbon dioxide) had an area under the curve of 0.91. CONCLUSIONS Cutaneous vasoconstriction phenotype is associated with the strongest risk of life-threatening allergy and thus may be regarded as pathognomonic of perioperative IgE-mediated anaphylaxis.
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Affiliation(s)
- Pascale Dewachter
- Department of Anesthesiology and Intensive Care, Assistance Publique-Hôpitaux de Paris, University Hospitals Paris Seine-Saint-Denis and Sorbonne Paris Nord University, Bobigny, France.
| | | | - Solohaja Faniaha Dimby
- Clinical Research Unit, Assistance Publique-Hôpitaux de Paris, University Hospitals Saint-Louis, Lariboisière and Fernand-Widal and Paris-Cité University, Paris, France
| | - Eric Vicaut
- Clinical Research Unit, Assistance Publique-Hôpitaux de Paris, University Hospitals Saint-Louis, Lariboisière and Fernand-Widal and Paris-Cité University, Paris, France
| | - Sadek Beloucif
- Department of Anesthesiology and Intensive Care, Assistance Publique-Hôpitaux de Paris, University Hospitals Paris Seine-Saint-Denis and Sorbonne Paris Nord University, Bobigny, France
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9
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Harris DE. Rocuronium-Induced Anaphylaxis in the Perioperative Period: A Clinical Review. AORN J 2024; 119:47-58. [PMID: 38149896 DOI: 10.1002/aorn.14053] [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: 07/14/2022] [Revised: 01/30/2023] [Accepted: 02/02/2023] [Indexed: 12/28/2023]
Abstract
Rocuronium, a nondepolarizing neuromuscular blocking agent used for muscle relaxation especially during endotracheal intubation, can cause hypersensitivity reactions. This article provides an overview of anaphylactic reactions; risk factors; and the pathophysiology, presentation, diagnosis, treatment, and nursing implications associated with rocuronium-induced anaphylaxis. Life-threatening anaphylaxis can be immunoglobulin E-mediated or non-immunoglobulin E-mediated and usually occurs after the first dose. Anaphylaxis can present with hypotension and bronchospasm; cutaneal symptoms, such as erythema, may not be obvious. Diagnosis is initially presumptive and may require a transesophageal echocardiogram to rule out other causes of hypotension (eg, pulmonary embolus). Emergency treatment begins with epinephrine administration and fluid boluses; cardiac support devices may be needed. Definitive diagnosis requires early measurement of histamine and tryptase levels and skin testing after the patient recovers from the reaction. Perioperative nurses should be prepared to participate in emergency treatment of anaphylaxis and advocate for testing for a definitive diagnosis.
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Hong AD, Fleissner ZJ, Campos-Cuellar C, Gonzalez-Estrada A, Mao SA, Doris Wang R, Pai SL. Kounis Syndrome, an Unrecognized Presentation of Perioperative Anaphylaxis in a Transplant Candidate. Prog Transplant 2023; 33:270-271. [PMID: 37533329 DOI: 10.1177/15269248231191485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2023]
Affiliation(s)
- Andrew D Hong
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Zachary J Fleissner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA
| | | | | | - Shennen A Mao
- Department of Transplantation, Mayo Clinic, Jacksonville, FL, USA
| | - R Doris Wang
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Sher-Lu Pai
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA
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11
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Ebo DG, van der Poorten MLM, Hopkins PM. Suspected perioperative anaphylaxis: are we making the correct diagnosis? Br J Anaesth 2023:S0007-0912(23)00235-0. [PMID: 37271719 DOI: 10.1016/j.bja.2023.05.002] [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: 03/23/2023] [Revised: 05/01/2023] [Accepted: 05/04/2023] [Indexed: 06/06/2023] Open
Abstract
We provide a commentary on aspects of a prospective study of the epidemiology of perioperative anaphylaxis in Japan (Japanese Epidemiologic Study for Perioperative Anaphylaxis [JESPA]). Accurate diagnosis of perioperative anaphylaxis is important for research but essential for clinical safety. We evaluate the diagnostic approach used in the JESPA study and caution against over-reliance on diagnostic tests that lack sensitivity and specificity when clinical data suggest an immediate perioperative hypersensitivity reaction is likely.
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Affiliation(s)
- Didier G Ebo
- Faculty of Medicine and Health Science, Department of Immunology-Allergology-Rheumatology, Antwerp University Hospital and the Infla-Med Center of Excellence, University of Antwerp, Antwerp, Belgium; Department of Immunology and Allergology, AZ Jan Palfijn Ghent, Ghent, Belgium.
| | - Marie-Line M van der Poorten
- Faculty of Medicine and Health Science, Department of Immunology-Allergology-Rheumatology, Antwerp University Hospital and the Infla-Med Center of Excellence, University of Antwerp, Antwerp, Belgium; Faculty of Medicine and Health Science, Department of Paediatrics, University of Antwerp, Antwerp University Hospital, Antwerp, Belgium
| | - Philip M Hopkins
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK; Department of Anaesthesia, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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12
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Pinnock TM, Volcheck GW, Smith MM, Murray AW, Renew JR, Smith BB. Perioperative anaphylactic reactions to central venous and pulmonary artery catheters containing chlorhexidine, sulfadiazine, or latex: a historical cohort study. Can J Anaesth 2023; 70:824-835. [PMID: 36829103 DOI: 10.1007/s12630-023-02403-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 10/18/2022] [Accepted: 10/24/2022] [Indexed: 02/26/2023] Open
Abstract
PURPOSE Central venous catheters (CVCs) and pulmonary artery catheters (PACs) containing chlorhexidine, silver sulfadiazine, or latex can cause perioperative anaphylaxis. We examined the incidence of and outcomes associated with anaphylaxis caused by CVCs/PACs. METHODS In a historical cohort study, we retrospectively identified adult patients fitted with CVCs/PACs at the Mayo Clinics in Minnesota, Arizona, and Florida from 1 January 2008 to 1 March 2018. Potential and confirmed cases of perioperative anaphylactic reactions were individually reviewed and classified. RESULTS During the study period, 39,505 procedures were performed during which CVCs/PACs were inserted. Of these, 2,937 patients with pre-existing chlorhexidine, sulfonamide (sulfa), and/or latex allergies had CVCs/PACs inserted that contained these substances. Perioperative anaphylaxis, in which CVCs/PACs were the confirmed or potential causative agent, occurred during 53 procedures. Seven patients had a preoperatively reported sulfa or latex allergy; no patients had a preoperative chlorhexidine allergy. Six of the seven patients with reported allergies to sulfa or latex had a CVC/PAC inserted that contained these substances. Twenty-four patients with anaphylaxis had postoperative allergic disease consultation; ten of these (42%) underwent skin testing. CONCLUSION Perioperative anaphylactic reactions related to CVCs/PACs containing chlorhexidine, silver sulfadiazine, or latex were rare in this large historical cohort study. We identified 2,937 patients with pre-existing chlorhexidine, sulfa, and/or latex allergies and had CVCs/PACs inserted that contained these substances. Although few cases of perioperative anaphylaxis attributable to these substances were observed in patients with corresponding allergies, the potential for substantial complication exists. Providers should be aware of the potential for these hidden exposures.
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Affiliation(s)
- Terrique M Pinnock
- School of Medicine, The City University of New York (CUNY), New York, NY, USA
| | | | - Mark M Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Andrew W Murray
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Johnathan R Renew
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Bradford B Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA.
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Takazawa T, Horiuchi T, Nagumo K, Sugiyama Y, Akune T, Amano Y, Fukuda M, Haraguchi T, Ishibashi C, Kanemaru E, Kato T, Katoh K, Kawano T, Kochiyama T, Kuri M, Kurita A, Matsuoka Y, Muramatsu T, Orihara M, Saito Y, Sato N, Shiraishi T, Suzuki K, Takahashi M, Takahashi T, Tanabe K, Tomioka A, Tomita Y, Tsuji T, Watanabe I, Yamada T, Yoshida N, Yamaguchi M, Saito S. The Japanese Epidemiologic Study for Perioperative Anaphylaxis, a prospective nationwide study: allergen exposure, epidemiology, and diagnosis of anaphylaxis during general anaesthesia. Br J Anaesth 2023:S0007-0912(23)00080-6. [PMID: 36990827 DOI: 10.1016/j.bja.2023.02.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 01/03/2023] [Accepted: 02/06/2023] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND Diagnosis of perioperative anaphylaxis is often challenging. This study describes the utility of a newly developed tool for identifying patients with a high possibility of anaphylaxis, and aimed to investigate the frequency of anaphylaxis with each drug during the perioperative period in Japan. METHODS This study included patients with anaphylaxis of Grade 2 or higher severity during general anaesthesia at 42 facilities across Japan in 2019 and 2020. We developed and adopted a unique objective evaluation tool yielding a composite score for diagnosing anaphylaxis, which includes the results of skin tests and basophil activation tests, and clinical scores for perioperative anaphylaxis. The number of cases using each drug and the total number of anaphylaxis cases were investigated to calculate the frequency of anaphylaxis. RESULTS General anaesthesia was performed in 218 936 cases, which included 55 patients with suspected perioperative anaphylaxis. The developed composite score diagnosed 43 of them with a high probability of anaphylaxis. The causative agent was identified in 32 cases. Plasma histamine levels showed high diagnostic accuracy for anaphylaxis. The top causative agents were rocuronium (10 cases in 210 852 patients, 0.005%), sugammadex (7 cases in 150 629 patients, 0.005%), and cefazolin (7 cases in 106 005 patients, 0.007%). CONCLUSIONS We developed a composite tool to diagnose anaphylaxis, and found that the combination of tryptase levels, skin testing, and basophil activation testing results and clinical score improved the certainty of anaphylaxis diagnosis. The incidence of perioperative anaphylaxis in our study was 1 in about 5000 general anaesthesia cases. CLINICAL TRIAL REGISTRATION UMIN000035350.
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14
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Kacha AK, Hicks MH, Mahrous C, Dalton A, Ben-Jacob TK. Management of Intraoperative Cardiac Arrest. Anesthesiol Clin 2023; 41:103-119. [PMID: 36871994 DOI: 10.1016/j.anclin.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
Perioperative arrests are both uncommon and heterogeneous and have not been described or studied to the same extent as cardiac arrest in the community. These crises are usually witnessed, frequently anticipated, and involve a rescuer physician with knowledge of the patient's comorbidities and coexisting anesthetic or surgically related pathophysiology ultimately leading to better outcomes. This article reviews the most probable causes of intraoperative arrest and their management.
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Affiliation(s)
- Aalok K Kacha
- Department of Anesthesia and Critical Care, Section of Critical Care Medicine, University of Chicago, 5841 South Maryland Avenue, MC 4028, Chicago, IL 60637, USA; Department of Surgery, Section of Transplant Surgery, University of Chicago, 5841 South Maryland Avenue, MC 4028, Chicago, IL 60637, USA.
| | - Megan Henley Hicks
- Department of Anesthesiology, Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist Medical Center, 1 Medical Center Boulevard, Winston-Salem, NC 27157, USA
| | - Christopher Mahrous
- Department of Anesthesiology, Cooper Medical School of Rowan University, One Cooper Plaza, Dorrance 2nd Floor, Camden, NJ 08103, USA
| | - Allison Dalton
- Department of Anesthesia and Critical Care, Section of Critical Care Medicine, University of Chicago, 5841 South Maryland Avenue, MC 4028, Chicago, IL 60637, USA
| | - Talia K Ben-Jacob
- Department of Anesthesiology, Division of Critical Care, Cooper Medical School of Rowan University, One Cooper Plaza, Dorrance 2nd Floor, Camden, NJ 08103, USA
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15
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Volcheck GW, Melchiors BB, Farooque S, Gonzalez-Estrada A, Mertes PM, Savic L, Tacquard C, Garvey LH. Perioperative Hypersensitivity Evaluation and Management: A Practical Approach. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:382-392. [PMID: 36436761 DOI: 10.1016/j.jaip.2022.11.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 10/04/2022] [Accepted: 11/01/2022] [Indexed: 11/27/2022]
Abstract
Perioperative hypersensitivity (POH) is an uncommon, potentially life-threatening event. Identification of POH can be difficult given the lack of familiarity, physiological effects of anesthesia, draping of the patient during surgery, and potential nonimmunological factors contributing to signs and symptoms. Given the unique nature and large number of medications administered in the perioperative setting, evaluation of POH can be challenging. In this paper, we present a practical approach to management with an emphasis on understanding what happens in the operating room, the overlap of signs and symptoms between nonimmunological and immunological reactions, acute management, and subsequent evaluation. In addition, we provide a strategy for further review of an initially negative evaluation and emphasize the importance of establishing management plans for the patient as well as providing recommendations to the medical, anesthesia, and surgical teams for future surgeries. A critical factor for successful management at all points in the process is a close collaboration between the anesthesia and the allergy teams.
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Affiliation(s)
- Gerald W Volcheck
- Division of Allergic Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minn.
| | | | - Sophie Farooque
- Frankland Allergy Clinic, Imperial College Healthcare NHS Trust, St. Mary's Hospital, London, UK
| | - Alexei Gonzalez-Estrada
- Division of Allergy, Asthma and Clinical Immunology, Department of Medicine, Mayo Clinic, Scottsdale, AZ
| | - Paul Michel Mertes
- Department of Anesthesia and Intensive Care, Strasbourg University Hospital, Strasbourg, France
| | - Louise Savic
- Department of Anaesthesia, Leeds Teaching Hospitals, NHS Trust, Leeds, UK
| | - Charles Tacquard
- Department of Anesthesia and Intensive Care, Strasbourg University Hospital, Strasbourg, France
| | - Lene Heise Garvey
- Allergy Clinic, Department of Dermatology and Allergy, Gentofte Hospital, Gentofte, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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16
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Cai H, Liu X, Wang D, Li W, Ma H, Zhao J. Management of Suspected Life-Threatening Perioperative Anaphylaxis and Risk Factors for Near-Fatal and Fatal Outcomes: A Retrospective Study in China. Ther Clin Risk Manag 2023; 19:383-394. [PMID: 37193306 PMCID: PMC10183184 DOI: 10.2147/tcrm.s406515] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 04/28/2023] [Indexed: 05/18/2023] Open
Abstract
Purpose Perioperative anaphylaxis (POA) is an acute severe systemic hypersensitivity reaction characterized by life-threatening respiratory and circulatory collapse. In our previous study, we reported the epidemiology of suspected POA in China. In the present study, we aimed to elucidate the management and outcomes of these cases and further verify the risk factors for near-fatal and fatal outcomes. Patients and Methods This was a retrospective study of 447 cases of suspected life-threatening POA encountered at 112 tertiary hospitals in mainland China between September 2018 and August 2019. Patient characteristics, symptoms, duration of hypotension, treatments, and clinical outcomes were documented. Bivariate logistic regression was used to identify risk factors for near-fatal and fatal outcomes. Results Most cases of suspected POA (89.9%) were recognized and treated within 5 min. Epinephrine was administered as the initial treatment in 232 (51.9%) cases. Corticosteroids (26.6%), other vasoactive drugs (18.3%), and bronchodilators (1.6%) were also administered as the initial treatment instead of epinephrine. The initial dosage of epinephrine (median, 35 µg) was insufficient according to the anaphylaxis guidelines. On multivariable analysis, age ≥65 years (odds ratio [OR] 7.48; 95% confidence interval [CI]: 1.33-41.87, P=0.022), ASA physical status IV (OR 17.68; 95% CI: 4.53-68.94; P<0.001), and hypotension duration ≥15 min (OR 3.63; 95% CI: 1.11-11.87; P=0.033) were risk factors for fatal and near-fatal outcomes. Conclusion Most cases in this study were managed in a timely manner, but the epinephrine application should be optimized according to the guidelines. Age ≥65 years, ASA physical status IV, and long-term hypotension were risk factors for near-fatal and fatal outcomes.
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Affiliation(s)
- Huamei Cai
- Department of Anesthesiology, China-Japan Friendship Hospital, Beijing, People’s Republic of China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People’s Republic of China
| | - Xiaowen Liu
- Department of Anesthesiology, China-Japan Friendship Hospital, Beijing, People’s Republic of China
| | - Dingyi Wang
- National Center for Respiratory Medicine & National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine & Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
- Department of Clinical Research and Data Management Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, People’s Republic of China
| | - Weixia Li
- Department of Anesthesiology, China-Japan Friendship Hospital, Beijing, People’s Republic of China
| | - Hongli Ma
- Department of Anesthesiology, China-Japan Friendship Hospital, Beijing, People’s Republic of China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People’s Republic of China
| | - Jing Zhao
- Department of Anesthesiology, China-Japan Friendship Hospital, Beijing, People’s Republic of China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People’s Republic of China
- Correspondence: Jing Zhao, Department of Anesthesiology, China- Japan Friendship Hospital, No. 2 Yinghua East Road, Beijing, 100029, People’s Republic of China, Tel +86 010 8420 5876, Email
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Ramsey A. Penicillin Allergy and Perioperative Anaphylaxis. FRONTIERS IN ALLERGY 2022; 3:903161. [PMID: 35769557 PMCID: PMC9234876 DOI: 10.3389/falgy.2022.903161] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 05/10/2022] [Indexed: 01/17/2023] Open
Abstract
Penicillin allergy is the most commonly reported drug allergy, while perioperative anaphylaxis is overall rare. This review covers the epidemiology of both penicillin allergy and perioperative anaphylaxis both separately and taken together. Considerations regarding anaphylaxis to penicillin during pregnancy are also discussed, since penicillin is the drug of choice for Group B Streptococcus prophylaxis. The minimal cross reactivity between penicillins and cephalosporins is addressed, since the vast majority of patients with a penicillin allergy label can receive perioperative cephalosporins. The management of the patient who has experienced perioperative anaphylaxis, including the importance of allergy referral is covered. Approaches to pre-operative penicillin allergy evaluations and opportunities for education are highlighted.
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Affiliation(s)
- Allison Ramsey
- Rochester Regional Health, Rochester, NY, United States
- Clinical Assistant Professor of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, United States
- *Correspondence: Allison Ramsey
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Epidemiology of perioperative anaphylaxis in the United States: new insights but more to learn and do. Br J Anaesth 2021; 128:7-10. [PMID: 34689992 DOI: 10.1016/j.bja.2021.09.017] [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: 08/11/2021] [Revised: 09/18/2021] [Accepted: 09/20/2021] [Indexed: 11/23/2022] Open
Abstract
Gonzalez-Estrada and colleagues report an estimated risk of severe or fatal perioperative anaphylaxis of one in 6,825 procedures during the period 2005-2014. This is slightly higher than that reported previously in France and England. Several predictors of near-fatal and fatal reactions are identified, such as increased age, cancer, and congestive cardiac failure.
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