1
|
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.
Collapse
Affiliation(s)
- Anna Littlejohns
- Anaesthetic Department, Leeds Teaching Hospitals Trust, Leeds, UK
| | | |
Collapse
|
2
|
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).
Collapse
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
| |
Collapse
|
3
|
Cook TM, Kane AD, Armstrong RA, Kursumovic E, Soar J. Peri-operative cardiac arrest due to suspected anaphylaxis as reported to the 7th National Audit Project of the Royal College of Anaesthetists. Anaesthesia 2024; 79:498-505. [PMID: 38205586 DOI: 10.1111/anae.16229] [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] [Accepted: 12/15/2023] [Indexed: 01/12/2024]
Abstract
The 7th National Audit Project (NAP7) of the Royal College of Anaesthetists studied peri-operative cardiac arrest. Among 59 cases reported as possible anaphylaxis, 33 (56%) were judged to be so by the review panel with high or moderate confidence. Causes in excluded cases included: isolated severe hypotension; bronchospasm; and oesophageal intubation. Severe bronchospasm leading to cardiac arrest was uncommon, but notably in one case led to a reported flat capnograph. In the baseline survey, anaesthetists estimated anaphylaxis as the cause of 10% of cases of peri-operative cardiac arrests and to be among the four most common causes. In a year-long registry of peri-operative cardiac arrest, suspected anaphylaxis was the seventh most common cause accounting for 4% of reports. Initial management was most often with low-dose intravenous adrenaline, and this was without complications. Both the NAP7 baseline survey and case registry provided evidence of reluctance to starting chest compressions when systolic blood pressure had fallen to below 50 mmHg and occasionally even when it was unrecordable. All 33 patients were resuscitated successfully but one patient later died. The one death occurred in a relatively young patient in whom chest compressions were delayed. Overall, peri-operative anaphylaxis leading to cardiac arrest occurred with a similar frequency and patterns of presentation, location, initial rhythm and suspected triggers in NAP7 as in the 6th National Audit Project (NAP6). Outcomes in NAP7 were generally better than for equivalent cases in NAP6.
Collapse
Affiliation(s)
- T M Cook
- Department of Anaesthesia and Intensive Care Medicine, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
- School of Medicine, University of Bristol, Bristol, UK
| | - A D Kane
- Department of Anaesthesia, James Cook University Hospital, Middlesbrough, UK
- Royal College of Anaesthetists, London, UK
| | - R A Armstrong
- Royal College of Anaesthetists, London, UK
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - E Kursumovic
- Department of Anaesthesia and Intensive Care Medicine, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
- Royal College of Anaesthetists, London, UK
| | - J Soar
- Department of Anaesthesia and Intensive Care Medicine, Southmead Hospital, Bristol, UK
| |
Collapse
|
4
|
Dodd A, Turner PJ, Soar J, Savic L. Emergency treatment of peri-operative anaphylaxis: Resuscitation Council UK algorithm for anaesthetists. Anaesthesia 2024; 79:535-541. [PMID: 38205901 DOI: 10.1111/anae.16206] [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] [Accepted: 11/18/2023] [Indexed: 01/12/2024]
Abstract
Peri-operative anaphylaxis is a rare but potentially catastrophic event which must be considered whenever unexpected and significant cardiovascular or respiratory compromise occurs during anaesthesia. The Resuscitation Council UK algorithm for peri-operative anaphylaxis highlights the importance of early intravenous adrenaline and fluid resuscitation and provides guidance on the treatment of refractory anaphylaxis and immediate follow-up. This algorithm is endorsed by the Royal College of Anaesthetists, Association of Anaesthetists, British Society of Allergy and Clinical Immunology and Clinical Immunology Professional Network of the British Society for Immunology. This document was produced by the Perioperative Allergy Network steering committee in collaboration with the Resuscitation Council UK.
Collapse
Affiliation(s)
- A Dodd
- Department of Anaesthesia, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - P J Turner
- Department of Paediatric Allergy and Clinical Immunology, National Heart and Lung Institute, Imperial College, London, UK
| | - J Soar
- Department of Anaesthesia and Intensive Care Medicine, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - L Savic
- Department of Anaesthesia, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| |
Collapse
|
5
|
Suzuki Y, Liu S, Yamashita N, Yamaguchi N, Takasaki Y, Yorozuya T, Mogi M. Perioperative Anaphylaxis in Japanese Secondary Care Institutions: Incidence, Causes, and the Imperative for Improved Diagnostic Practices. Cureus 2024; 16:e57555. [PMID: 38707122 PMCID: PMC11068509 DOI: 10.7759/cureus.57555] [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: 04/03/2024] [Indexed: 05/07/2024] Open
Abstract
Background This research investigates the incidence, suspected causes, and diagnostic procedures for perioperative anaphylaxis (POA), a potentially severe complication, in secondary care hospitals across Japan. Methodology We surveyed Saiseikai hospitals and gathered data on surgical procedures, POA occurrences, potential triggers, and diagnostic methods. Results Among 70,523 surgeries, seven were associated with POA, resulting in an approximate incidence rate of 0.01%. Rocuronium was the most commonly suspected trigger, followed by sugammadex, latex, and angiography contrast agents. Despite the importance of skin tests as the most basic and crucial diagnostic method, they were conducted in only three instances. No in vitro tests for drug identification were conducted, and in four cases, the cause was determined merely based on the timing of drug administration, indicating significant diagnostic limitations. Conclusions The study underscores the critical situation in Japan regarding insufficient diagnostic practices and difficulties in identifying triggering drugs rather than the consistent prevalence of POA in secondary care facilities. The findings emphasize the need for improved diagnostic proficiency and more rigorous drug identification practices to ensure prompt and accurate POA diagnosis. It is essential to conduct further research and interventions to increase patient safety during the perioperative period in secondary care settings.
Collapse
Affiliation(s)
- Yasuyuki Suzuki
- Anesthesiology, Saiseikai Matsuyama Hospital, Matsuyama, JPN
- Research Division, Saiseikai Research Institute of Health Care and Welfare, Tokyo, JPN
- Department of Pharmacology, Ehime University Graduate School of Medicine, Toon, JPN
| | - Shuang Liu
- Department of Pharmacology, Ehime University Graduate School of Medicine, Toon, JPN
| | - Natsumi Yamashita
- Clinical Research Center, National Hospital Organization Shikoku Cancer Center, Matsuyama, JPN
| | - Naohito Yamaguchi
- Research Division, Saiseikai Research Institute of Health Care and Welfare, Tokyo, JPN
| | - Yasushi Takasaki
- Department of Anesthesia and Perioperative Medicine, Ehime University Graduate School of Medicine, Toon, JPN
| | - Toshihiro Yorozuya
- Department of Anesthesia and Perioperative Medicine, Ehime University Graduate School of Medicine, Toon, JPN
| | - Masaki Mogi
- Department of Pharmacology, Ehime University Graduate School of Medicine, Toon, JPN
| |
Collapse
|
6
|
Sadleir PHM, Clarke RC, Platt PR. Association of antibiotic test doses with reduced likelihood of severe antibiotic anaphylaxis: a re-analysis of data from the 6th National Audit Project (NAP6). Br J Anaesth 2024; 132:621-624. [PMID: 38182529 DOI: 10.1016/j.bja.2023.12.007] [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] [Received: 09/20/2023] [Revised: 10/28/2023] [Accepted: 12/05/2023] [Indexed: 01/07/2024] Open
Affiliation(s)
- Paul H M Sadleir
- Sir Charles Gairdner Hospital, Department of Anaesthesia, Perth, WA, Australia; Western Australian Anaesthetic Allergy Clinic, Perth, WA, Australia; Department of Pharmacology, University of Western Australia, Perth, WA, Australia.
| | - Russell C Clarke
- Sir Charles Gairdner Hospital, Department of Anaesthesia, Perth, WA, Australia; Western Australian Anaesthetic Allergy Clinic, Perth, WA, Australia
| | - Peter R Platt
- Sir Charles Gairdner Hospital, Department of Anaesthesia, Perth, WA, Australia; Western Australian Anaesthetic Allergy Clinic, Perth, WA, Australia
| |
Collapse
|
7
|
Horiuchi T, Takazawa T, Haraguchi T, Orihara M, Nagumo K, Saito S. Investigating the optimal diagnostic value of histamine for diagnosing perioperative hypersensitivity: a prospective, observational study. J Anesth 2023:10.1007/s00540-023-03199-z. [PMID: 37156974 DOI: 10.1007/s00540-023-03199-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 04/29/2023] [Indexed: 05/10/2023]
Abstract
Although several guidelines recommend measuring blood tryptase and histamine concentrations to diagnose perioperative anaphylaxis (POA), tryptase measurement is more common. The appropriate timing of blood collection and the diagnostic threshold for histamine measurement are still controversial. To address these issues, histamine concentrations in patients with anaphylaxis and those with anaphylaxis-uncertain were compared in our previous study, the Japanese Epidemiologic Study for Perioperative Anaphylaxis (JESPA). However, because we could not rule out the possibility that the anaphylactic-uncertain group included anaphylactic patients, histamine concentrations were measured in patients who underwent general anesthesia with no complications as controls in the present study. Histamine levels were measured at anesthesia induction (baseline), 30 min (first point), and 2 h (second point) after the start of surgery in 30 control patients. Histamine concentrations in controls were lower than in patients with POA in JESPA at the first and second points. At the first point, a threshold of 1.5 ng/ml resulted in sensitivity of 77% and specificity of 100%. A threshold of 1.1 ng/ml at the second point resulted in sensitivity of 67% and specificity of 87%. Measurement of histamine concentrations within two hours after symptom onset might help diagnose POA.
Collapse
Affiliation(s)
- Tatsuo Horiuchi
- Department of Anesthesiology, Gunma University Graduate School of Medicine, 3-39-22 Showa-Machi, Maebashi, Gunma, 371-8511, Japan
| | - Tomonori Takazawa
- Intensive Care Unit, Gunma University Hospital, 3-39-15 Showa-Machi, Maebashi, Gunma, 371-8511, Japan.
| | - Takashi Haraguchi
- Department of Anesthesiology, Gunma University Graduate School of Medicine, 3-39-22 Showa-Machi, Maebashi, Gunma, 371-8511, Japan
| | - Masaki Orihara
- Intensive Care Unit, Gunma University Hospital, 3-39-15 Showa-Machi, Maebashi, Gunma, 371-8511, Japan
| | - Kazuhiro Nagumo
- Department of Anesthesiology, Gunma University Graduate School of Medicine, 3-39-22 Showa-Machi, Maebashi, Gunma, 371-8511, Japan
| | - Shigeru Saito
- Department of Anesthesiology, Gunma University Graduate School of Medicine, 3-39-22 Showa-Machi, Maebashi, Gunma, 371-8511, Japan
| |
Collapse
|