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Pallardy M, Bechara R, Whritenour J, Mitchell-Ryan S, Herzyk D, Lebrec H, Merk H, Gourley I, Komocsar WJ, Piccotti JR, Balazs M, Sharma A, Walker DB, Weinstock D. Drug hypersensitivity reactions: review of the state of the science for prediction and diagnosis. Toxicol Sci 2024; 200:11-30. [PMID: 38588579 PMCID: PMC11199923 DOI: 10.1093/toxsci/kfae046] [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] [Indexed: 04/10/2024] Open
Abstract
Drug hypersensitivity reactions (DHRs) are a type of adverse drug reaction that can occur with different classes of drugs and affect multiple organ systems and patient populations. DHRs can be classified as allergic or non-allergic based on the cellular mechanisms involved. Whereas nonallergic reactions rely mainly on the innate immune system, allergic reactions involve the generation of an adaptive immune response. Consequently, drug allergies are DHRs for which an immunological mechanism, with antibody and/or T cell, is demonstrated. Despite decades of research, methods to predict the potential for a new chemical entity to cause DHRs or to correctly attribute DHRs to a specific mechanism and a specific molecule are not well-established. This review will focus on allergic reactions induced by systemically administered low-molecular weight drugs with an emphasis on drug- and patient-specific factors that could influence the development of DHRs. Strategies for predicting and diagnosing DHRs, including potential tools based on the current state of the science, will also be discussed.
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Affiliation(s)
- Marc Pallardy
- Université Paris-Saclay, INSERM, Inflammation Microbiome Immunosurveillance, Orsay, 91400, France
| | - Rami Bechara
- Université Paris-Saclay, INSERM, CEA, Center for Research in Immunology of Viral, Autoimmune, Hematological and Bacterial Diseases (IMVA-HB), Le Kremlin Bicêtre, 94270, France
| | - Jessica Whritenour
- Pfizer Worldwide Research, Development and Medical, Groton, Connecticut 06340, USA
| | - Shermaine Mitchell-Ryan
- The Health and Environmental Science Institute, Immunosafety Technical Committee, Washington, District of Columbia 20005, USA
| | - Danuta Herzyk
- Merck & Co., Inc, West Point, Pennsylvania 19486, USA
| | - Herve Lebrec
- Amgen Inc., Translational Safety and Bioanalytical Sciences, South San Francisco, California 94080, USA
| | - Hans Merk
- Department of Dermatology and Allergology, RWTH Aachen University, Aachen, 52062, Germany
| | - Ian Gourley
- Janssen Research & Development, LLC, Immunology Clinical Development, Spring House, Pennsylvania 19002, USA
| | - Wendy J Komocsar
- Immunology Business Unit, Eli Lilly and Company, Indianapolis, Indiana 46225, USA
| | | | - Mercedesz Balazs
- Genentech, Biochemical and Cellular Pharmacology, South San Francisco, California 94080, USA
| | - Amy Sharma
- Pfizer, Drug Safety Research & Development, New York 10017, USA
| | - Dana B Walker
- Novartis Institute for Biomedical Research, Preclinical Safety-Translational Immunology and Clinical Pathology, Cambridge, Massachusetts 02139, USA
| | - Daniel Weinstock
- Janssen Research & Development, LLC, Preclinical Sciences Translational Safety, Spring House, Pennsylvania 19002, USA
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Kempenaers S, Hansen TG, Van de Velde M. Remimazolam and serious adverse events: A scoping review. Eur J Anaesthesiol 2023; 40:841-853. [PMID: 37727906 DOI: 10.1097/eja.0000000000001902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
Remimazolam is anticipated to be an interesting anaesthetic and sedative. It combines the pharmacodynamic properties of midazolam with pharmacokinetic properties similar to remifentanil. However, worrisome case reports of anaphylaxis, delayed emergence and re-sedation have emerged recently and necessitate further investigation.PubMed (including MEDLINE) and EMBASE were searched for all studies reporting serious adverse events where remimazolam was administered for sedation or anaesthesia.Thirty-six case reports and 73 trials were identified, involving a total of 6740 patients who received remimazolam. Hypotension was reported in 911 cases, delayed emergence in 68 cases, anaphylaxis in 10 cases and re-sedation in 8 cases. The incidence of hypotension seems to be lower compared with other anaesthetics, even in high-risk patients.Delayed emergence might be related to the metabolism of remimazolam through carboxylesterase 1 (CES1), a tissue esterase predominant in the liver. There is significant interindividual variation, and it is inhibited by flavonoids, fatty acids and alcohol. Individual benzodiazepine sensitivity has also been reported. A higher BMI, older age and low plasma albumin concentration are risk factors for delayed emergence. Anaphylaxis might be related to a non-IgE-mediated effect of the excipient dextran-40 or a partially IgE-mediated reaction to remimazolam itself. Resedation has been reported after flumazenil reversal and is explained by the specific pharmacokinetic properties of flumazenil and remimazolam. Reversal by flumazenil should be reserved for and used carefully in patients with delayed emergence. VISUAL ABSTRACT http://links.lww.com/EJA/A864 .
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Affiliation(s)
- Sander Kempenaers
- From the Department of Anaesthesiology, University Hospitals Leuven, Leuven, Belgium (SK), Department of Anaesthesia and Intensive Care, Akershus University Hospital, Lorenskog (TGH), Faculty of Medicine, Institute of Clinical Medicine, Oslo University, Oslo, Norway (TGH), Department of Cardiovascular Sciences, KU Leuven (MVdV) and Department of Anaesthesiology, University Hospitals Leuven, Leuven, Belgium (MVdV)
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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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Watanabe Y, Miyagi M, Kaneda T. Anesthetic Management of a Patient With Massive Pulmonary Secretion During Cardiopulmonary Bypass Probably Due to Transfusion-Related Acute Lung Injury Type Ⅱ. Cureus 2023; 15:e37405. [PMID: 37182034 PMCID: PMC10171924 DOI: 10.7759/cureus.37405] [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: 04/10/2023] [Indexed: 05/16/2023] Open
Abstract
Transfusion-related acute lung injury (TRALI) is potentially life-threatening adverse reaction associated with blood transfusion and can induce perioperative pulmonary secretion. TRALI that develops during cardiopulmonary bypass (CPB) may be difficult to detect; however, the pathophysiology might manifest as derangements in CPB operations. A 79-year-old man was scheduled to undergo partial replacement of the aortic arch with CPB. Two units of red blood cells were loaded into the priming solution. Although the vital signs, including oxygenation, remained stable in the prebypass period, perfusionists noticed a decreasing trend in the venous reservoir level early in the CPB operations. The trend continued even during circulatory arrest with selective cerebral perfusion, resulting in the termination of the modified hemofiltration. Surgical procedures were accomplished uneventfully; however, a large amount of fluid was required to maintain the minimal reservoir level and CPB flow. The total fluid balance during CPB was +8,233 mL, which was quite unusual in our practice. When 800 mL of massive pulmonary secretion was detected before CPB withdrawal, the etiology could not be determined simultaneously; nonetheless, systemic vascular hyperpermeability was speculated to be the underlying pathophysiology. Our therapeutic approach following the treatment of acute respiratory distress syndrome contributed to halting the deterioration of lung injury. Although the pneumothorax developed on the first postoperative day, the patient was treated with the insertion of a chest drainage tube. Subsequently, the patient had a good course and was discharged without respiratory complications. In conclusion, massive pulmonary secretion, probably due to TRALI type II, was associated with derangements in CPB operations. Prompt identification of the underlying pathophysiology and appropriate intervention is crucial.
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Affiliation(s)
- Yasuhiro Watanabe
- Department of Anesthesia, Japanese Red Cross Shizuoka Hospital, Shizuoka, JPN
| | - Mitsumasa Miyagi
- Department of Anesthesia, Japanese Red Cross Shizuoka Hospital, Shizuoka, JPN
| | - Toru Kaneda
- Department of Anesthesia, Japanese Red Cross Shizuoka Hospital, Shizuoka, JPN
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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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Could Artificial Intelligence Prevent Intraoperative Anaphylaxis? Reference Review and Proof of Concept. Medicina (B Aires) 2022; 58:medicina58111530. [PMID: 36363487 PMCID: PMC9694532 DOI: 10.3390/medicina58111530] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 10/17/2022] [Accepted: 10/24/2022] [Indexed: 01/25/2023] Open
Abstract
Drugs and various medical substances have been used for many decades to diagnose or treat diseases. Procedures like surgery and anesthesia (either local or general) use different pharmacological products during these events. In most of the cases, the procedure is safe and the physician performs the technique without incidents. Although they are safe for use, these substances (including drugs) may have adverse effects, varying from mild ones to life-threatening reactions in a minority of patients. Artificial intelligence may be a useful tool in approximating the risk of anaphylaxis before undertaking a medical procedure. This material presents these undesirable responses produced by medical products from a multidisciplinary point of view. Moreover, we present a proof of concept for using artificial intelligence as a possible guardship against intraoperative anaphylaxis.
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Combined Treatment with KV Channel Inhibitor 4-Aminopyridine and either γ-Cystathionine Lyase Inhibitor β-Cyanoalanine or Epinephrine Restores Blood Pressure, and Improves Survival in the Wistar Rat Model of Anaphylactic Shock. BIOLOGY 2022; 11:biology11101455. [PMID: 36290359 PMCID: PMC9598754 DOI: 10.3390/biology11101455] [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: 08/19/2022] [Revised: 09/25/2022] [Accepted: 09/29/2022] [Indexed: 11/07/2022]
Abstract
Simple Summary Allergic diseases are presenting a constant increase all over the world and caused by such different substances as food, drugs, and pollens. Anaphylactic shock is the more severe complication of allergy which can induce death if the treatment is not administered immediately. Some patients do not respond to the recommended treatment, intra venous or intramuscular epinephrine. The pathophysiology of anaphylactic shock is still under investigation. The mediators released after the activation of mast cells and basophiles act on endothelial cells and smooth muscle cells, inducing the vasodilation responsible for hypotension and shock. Nitric oxide and hydrogen sulphide are both intracellular mediators that induce vasodilation. The role of potassium voltage dependent channels is suspected. We aimed to demonstrate the ability of a blocker of potassium voltage dependent channels, 4-aminopyridine, alone or in combination with inhibitors of cystathionine γ-lyase to restore blood pressure and improve survival in an ovalbumin rat anaphylactic shock model. The blockade of potassium voltage dependent channels alone or combined with inhibitors of cystathionine γ-lyase, dl-propargylglycine, or β-cyanoalanine restored blood pressure and improved survival. These findings suggest possible investigative treatment pathways for research concerning epinephrine-refractory anaphylactic shock in patients. Abstract The mechanism of anaphylactic shock (AS) remains incompletely understood. The potassium channel blocker 4-aminopyridine (4-AP), the inhibitors of cystathionine γ-lyase (ICSE), dl-propargylglycine (DPG) or β-cyanoalanine (BCA), and the nitric oxide (NO) synthase produce vasoconstriction and could be an alternative for the treatment of AS. The aim of this study was to demonstrate the ability of L-NAME, ICSE alone or in combination with 4-AP to restore blood pressure (BP) and improve survival in ovalbumin (OVA) rats AS. Experimental groups included non-sensitized Wistar rats (n = 6); AS (n = 6); AS (n = 10 per group) treated i.v. with 4-AP (AS+4-AP), epinephrine (AS+EPI), AS+DPG, AS+BCA, or with L-NAME (AS+L-NAME); or AS treated with drug combinations 4-AP+DPG, 4-AP+BCA, 4-AP+L-NAME, or 4-AP+EPI. AS was induced by i.v. OVA (1 mg). Treatments were administered i.v. one minute after AS induction. Mean arterial BP (MAP), heart rate (HR), and survival were monitored for 60 min. Plasma levels of histamine, prostaglandin E2 (PGE2) and F2 (PGF2α), leukotriene B4 and C4, angiotensin II, vasopressin, oxidative stress markers, pH, HCO3, PaO2, PaCO2, and K+ were measured. OVA induced severe hypotension and all AS rats died. Moreover, 4-AP, 4-AP+EPI, or 4-AP+BCA normalized both MAP and HR and increased survival. All sensitized rats treated with 4-AP alone or with 4-AP+BCA survived. The time-integrated MAP “area under the curve” was significantly higher after combined 4-AP treatment with ICSE. Metabolic acidosis was not rescued and NO, ICSE, and Kv inhibitors differentially alter oxidative stress and plasma levels of anaphylactic mediators. The AS-induced reduction of serum angiotensin II levels was prevented by 4-AP treatment alone or in combination with other drugs. Further, 4-AP treatment combined with EPI or with BCA also increased serum PGF2α, whereas only the 4-AP+EPI combination increased serum LTB4. Serum vasopressin and angiotensin II levels were increased by 4-AP treatment alone or in combination with other drugs. Moreover, 4-AP alone and in combination with inhibition of cystathionine γ-lyase or EPI normalizes BP, increases serum vasoconstrictor levels, and improves survival in the Wistar rat model of AS. These findings suggest possible investigative treatment pathways for research into epinephrine-refractory anaphylactic shock in patients.
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Hasushita Y, Nagao M, Miyazawa Y, Yunoki K, Mima H. Cardiac Arrest Following Remimazolam-Induced Anaphylaxis: A Case Report. A A Pract 2022; 16:e01616. [PMID: 36149988 PMCID: PMC9521581 DOI: 10.1213/xaa.0000000000001616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2022] [Indexed: 11/29/2022]
Abstract
Remimazolam is a recently approved benzodiazepine sedative. We report a case of a 72-year-old man who experienced a cardiac arrest due to severe anaphylaxis immediately after general anesthesia induction. Based on the results of skin tests, including those for dextran 40, an excipient in the remimazolam solution, and a review of drugs given during 3 anesthetics, remimazolam was identified as the probable causative agent. Although remimazolam is structurally similar to midazolam, the patient was not allergic to midazolam as demonstrated before and after anaphylaxis. This report highlights the potential risk of allergic reactions to remimazolam.
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Affiliation(s)
| | - Megumi Nagao
- Dermatology, Kobe City Medical Center General Hospital, Kobe, Japan
| | | | - Kazuma Yunoki
- From the Departments of Anesthesiology and Intensive Care
| | - Hiroyuki Mima
- From the Departments of Anesthesiology and Intensive Care
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The Safety Profile of General and Local Anaesthetic Agents: Data Collected during 20 Years of Spontaneous Reporting Activities in the Campania Region (Southern Italy). Pharmaceuticals (Basel) 2021; 14:ph14121261. [PMID: 34959662 PMCID: PMC8703922 DOI: 10.3390/ph14121261] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 11/30/2021] [Accepted: 12/01/2021] [Indexed: 12/19/2022] Open
Abstract
Background: General and local anaesthetics are widely used during surgery. These drugs have peculiar safety profiles, being commonly associated with mild and reversible local adverse drug reactions (ADRs), but also with more severe and systemic ADRs, including respiratory and cardiovascular depression and anaphylaxis. Methods and Objectives: We carried out a descriptive analysis of Individual Case Safety Reports (ICSRs) sent to the Campania Regional Centre of Pharmacovigilance (Southern Italy) from 2001 to 2021 that reported general or local anaesthetics as suspected drugs, with the aim of describing their overall characteristics, focussing on the ADRs’ seriousness and distribution by System Organ Class (SOC) and Preferred Term (PT). Results: A total of 110 ICSRs documenting general or local anaesthetics were sent to the Italian pharmacovigilance database during 20 years of spontaneous reporting activities in the Campania region. ADRs mainly occurred in patients with a median age of 48 years and in a slightly higher percentage of men. ADRs were more commonly classified as not serious and had a favourable outcome. In terms of ADRs’ distribution by SOC and PT, both general and local anaesthetics were associated with general and cutaneous disorders, with common ADRs that included lack of efficacy, rash, and erythema. In addition, general anaesthetics were associated with the occurrence of respiratory ADRs, while local anaesthetics were associated with the occurrence of nervous ADRs. Conclusion: Even though a limited number of ICSRs documenting anaesthetics-induced ADRs were retrieved from the Italian spontaneous reporting database in the Campania region, we believe that the continuous monitoring of these drugs is highly recommended, especially among the frail population.
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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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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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12
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Adverse Reactions to Illicit Drugs (Marijuana, Opioids, Cocaine) and Alcohol. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:3006-3014. [PMID: 33965592 DOI: 10.1016/j.jaip.2021.04.061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 04/19/2021] [Accepted: 04/25/2021] [Indexed: 12/28/2022]
Abstract
Drug allergy has been a research topic within the allergy field for decades. However, many drug reactions presumed to be of allergic nature are not and originate from different mechanisms. Drug-induced reactions can affect numerous organ systems, present with various symptoms, and have more than 1 mechanism of action. In this rostrum article, we want to give an overview of the different allergic and nonallergic reactions that can be expected with the (illicit) use of cannabis, cocaine, opioids, and alcohol. In addition, this article focuses on the different methods available to diagnose allergy related to these 4 drug types and highlight the pitfalls of nonallergic reactions or allergy "mimickers" complicating the diagnosis of true drug allergy. Finally, the impact on current medical practices and future research in support of the allergist in diagnosis and treatment of these medical problems is addressed.
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Koca Kalkan I, Koycu Buhari G, Ates H, Basa Akdogan B, Erdem Ozdedeoglu O, Aksu K, Oner Erkekol F. Identification of Risk Factors and Cross-Reactivity of Local Anesthetics Hypersensitivity: Analysis of 14-Years' Experience. J Asthma Allergy 2021; 14:47-58. [PMID: 33519213 PMCID: PMC7837570 DOI: 10.2147/jaa.s292442] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 12/31/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose Local anesthetics (LA) are widely used and adverse drug reactions (ADR) occur in 2.5–10%, but hypersensitivity reactions are rare (ranging between 0% and 4.3%). Risk is so overestimated causing too many allergy clinic referrals. There are limited and also conflicting results over the management of LA allergy. We aimed to find out who should be referred to an allergy clinic for a LA allergy testing, to define the subjects with an increased risk of LA allergy and to assess the need for testing for identifying alternative LA. Patients and Methods We performed a retrospective study of patients referred to our clinic for diagnostic workup of LA hypersensitivity from 2006 to 2020. Results In our cohort of 398 patients, tests were positive in 14 (3.52%) of them. Personal history of ADR with LA was the only independent risk factor for positive test (RR=4.007, p=0.033). Presence of generalized cutaneous symptoms and hypotension during past reaction were independent predictors of positive test (RR=9.043, p=0.021 and RR=10.445, p=0.038, respectively). The negative predictive value of intradermal test at dilution of 1:100 for immediate-type reaction was high (97.56%). Also, we demonstrated cross-reactivity within the amide-group LAs and co-occurrence of immediate- and delayed-type reactions. Conclusion Only patients with an LA-induced ADR should be referred to an allergy clinic. History of generalized cutaneous symptoms and/or hypotension during the reaction may define subjects with an increased risk of LA allergy. A stepwise test procedure may start with skin tests especially for these patients with increased risk factors. In presence of LA allergy, alternative LA should always be confirmed by performing a challenge test.
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Affiliation(s)
- Ilkay Koca Kalkan
- Department of Immunology and Allergy, Atatürk Chest Diseases and Thoracic Surgery Training and Research Hospital, Ankara, Turkey
| | - Gozde Koycu Buhari
- Department of Immunology and Allergy, Atatürk Chest Diseases and Thoracic Surgery Training and Research Hospital, Ankara, Turkey
| | - Hale Ates
- Department of Immunology and Allergy, Atatürk Chest Diseases and Thoracic Surgery Training and Research Hospital, Ankara, Turkey
| | - Buket Basa Akdogan
- Department of Immunology and Allergy, Atatürk Chest Diseases and Thoracic Surgery Training and Research Hospital, Ankara, Turkey
| | - Ozlem Erdem Ozdedeoglu
- Department of Immunology and Allergy, Atatürk Chest Diseases and Thoracic Surgery Training and Research Hospital, Ankara, Turkey
| | - Kurtulus Aksu
- Department of Immunology and Allergy, Atatürk Chest Diseases and Thoracic Surgery Training and Research Hospital, Ankara, Turkey
| | - Ferda Oner Erkekol
- Division of Immunology and Allergy, Department of Chest Diseases, Ankara Yıldırım Beyazıt University School of Medicine, Ankara, Turkey
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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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15
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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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16
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Croke L. Guideline for care of the patient receiving local-only anesthesia. AORN J 2020; 112:P8-P9. [PMID: 32990958 DOI: 10.1002/aorn.13228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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17
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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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18
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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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19
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Patil SS, Sun L, Fox CJ, Anthony KE, Anzalone FA, Fisher PM, Girma B, Huang GJ, Barsley EL, Cornett EM, Urman RD, Kaye AD. Multiple drug allergies: Recommendations for perioperative management. Best Pract Res Clin Anaesthesiol 2020; 34:325-344. [PMID: 32711838 DOI: 10.1016/j.bpa.2020.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 05/20/2020] [Indexed: 02/06/2023]
Abstract
Life-threatening hypersensitivity reactions are more likely to occur in patients with a history of allergy, atopy, or asthma. Hence, in a patient who presented with a history of multiple drug allergies (MDA), an allergological assessment should be performed prior to surgical procedure. Drug allergies, being one of the causes of catastrophic events occurring in the perioperative period, are of major concern to anesthesiologists. Neuromuscular blocking agents are regularly used during anesthesia and are one of the most common causes of perioperative anaphylaxis. They are estimated to be responsible for 50%-70% of perioperative hypersensitivity reactions. Antibiotics and latex represent the next two groups of drug allergy. Allergic reactions to propofol are rare with an incidence of 1:60,000 exposures. Although intraoperative drug anaphylaxis is rare, it contributes to 4.3% of deaths occurring during general anesthesia. These recommendations discuss pathophysiology of MDA, preoperative evaluation, and anesthesia considerations as well as the prevention and management of allergic reactions in anesthetized patients with a history of MDA.
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Affiliation(s)
- Shilpadevi S Patil
- Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA, 71103, USA.
| | - Lu Sun
- School of Medicine, LSU Health Sciences Center New Orleans, 2020 Gravier Street, New Orleans, LA, 70112, USA.
| | - Charles J Fox
- Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA, 71103, USA.
| | | | - Fallon A Anzalone
- LSU Health Sciences Center New Orleans, 433 Bolivar Street, New Orleans, LA, 70112, USA.
| | - Paul M Fisher
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Brook Girma
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Genkai J Huang
- Division of Family Medicine, HCA Houston Healthcare West, 12141 Richmond Ave. Houston, TX, 77082, USA.
| | - Emily L Barsley
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Elyse M Cornett
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA.
| | - Alan D Kaye
- Departments of Anesthesiology and Pharmacology, Toxicology, and Neurosciences, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA.
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20
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Linauskienė K, Grincevičienė G, Malinauskienė L, Blažienė A, Chomičienė A. Severe anaphylactic reaction to cisatracurium during anesthesia with cross-reactivity to atracurium. Open Med (Wars) 2020; 15:384-386. [PMID: 33313402 PMCID: PMC7706132 DOI: 10.1515/med-2020-0126] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 03/31/2020] [Accepted: 04/01/2020] [Indexed: 11/15/2022] Open
Abstract
A case of a severe anaphylactic reaction during general anesthesia was reported. Despite the high suspicion for cefuroxime as a trigger of the anaphylactic reaction, cisatracurium emerged being the culprit drug. This case illustrates the importance of testing all drugs used during procedures/operations, trying to find a culprit of anaphylaxis.
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Affiliation(s)
- Kotryna Linauskienė
- Vilnius University, Faculty of Medicine, Institute of Clinical, Medicine, Department of Chest diseases, Immunology and Allergology, Vilnius, Lithuania. Santariskiu 2, Vilnius LT-08661, Vilnius, Lithuania
| | - Gintarė Grincevičienė
- Outpatient department, Republican Panevezys Hospital Smėlynės g. 25, LT-35144, Panevėžys, Lithuania
| | - Laura Malinauskienė
- Vilnius University, Faculty of Medicine, Institute of Clinical Medicine, Department of Chest diseases, Immunology and Allergology, Vilnius, Lithuania. Santariskiu 2, Vilnius LT-08661, Vilnius, Lithuania
| | - Audra Blažienė
- Vilnius University, Faculty of Medicine, Institute of Clinical Medicine, Department of Chest diseases, Immunology and Allergology, Lithuania. Santariskiu 2, Vilnius LT-08661, Vilnius, Lithuania
| | - Anželika Chomičienė
- Vilnius University, Faculty of Medicine, Institute of Clinical Medicine, Department of Chest diseases, Immunology and Allergology, Vilnius, Lithuania. Santariskiu 2, Vilnius LT-08661, Vilnius, Lithuania
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21
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Gonzalez-Diaz SN, de Lira-Quezada CE, Villarreal-Gonzalez RV, Guzman-Avilan RI, Macouzet-Sanchez C, Galindo-Rodriguez G. Perioperative Anaphylaxis. CURRENT TREATMENT OPTIONS IN ALLERGY 2020. [DOI: 10.1007/s40521-020-00250-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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22
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van Cuilenborg VR, Hermanides J, Bos EME, Hollmann MW, Preckel B, Kooij FO, Terreehorst I. Perioperative approach of allergic patients. Best Pract Res Clin Anaesthesiol 2020; 35:11-25. [PMID: 33742571 DOI: 10.1016/j.bpa.2020.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 03/23/2020] [Indexed: 12/18/2022]
Abstract
Perioperative allergic reactions are rare, yet important complications of anesthesia. Severe, generalized allergic reactions called anaphylaxis are estimated to have a mortality of 3.5-4.8%. Adequate recognition and handling of a severe perioperative anaphylactic reaction result in better outcomes, including less hypoxic-ischemic encephalopathy and death. The diagnosis of a perioperative allergic reaction can be difficult as the list of possible culprits of a perioperative allergic reaction is extensive. Making an informed guess on the causative agent and avoiding this agent in future anesthesia procedures is undesirable and unsafe. Therefore, to ensure future patient safety, a thorough investigation following a perioperative allergic reaction is mandatory. A collaborate approach by allergists and anesthesiologists is advised. In this article, we discuss the basic approach of the allergic patient and of patients with a suspected allergy to perioperatively administered medication.
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Affiliation(s)
- Vincent R van Cuilenborg
- Dutch Perioperative Allergy Centre, Amsterdam University Medical Centres, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands; Department of Anaesthesiology, Amsterdam University Medical Centres, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.
| | - Jeroen Hermanides
- Dutch Perioperative Allergy Centre, Amsterdam University Medical Centres, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands; Department of Anaesthesiology, Amsterdam University Medical Centres, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.
| | - Elke M E Bos
- Dutch Perioperative Allergy Centre, Amsterdam University Medical Centres, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands; Department of Anaesthesiology, Amsterdam University Medical Centres, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.
| | - Markus W Hollmann
- Department of Anaesthesiology, Amsterdam University Medical Centres, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.
| | - Benedikt Preckel
- Department of Anaesthesiology, Amsterdam University Medical Centres, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.
| | - Fabian O Kooij
- Dutch Perioperative Allergy Centre, Amsterdam University Medical Centres, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands; Department of Anaesthesiology, Amsterdam University Medical Centres, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.
| | - Ingrid Terreehorst
- Dutch Perioperative Allergy Centre, Amsterdam University Medical Centres, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands; Department of Otorhinolaryngology, Amsterdam University Medical Centres, Location AMC, Meibergdreef 9, 1105 AZ, the Netherlands.
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23
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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: 125] [Impact Index Per Article: 25.0] [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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24
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Stepanovic B, Sommerfield D, Lucas M, von Ungern-Sternberg BS. An update on allergy and anaphylaxis in pediatric anesthesia. Paediatr Anaesth 2019; 29:892-900. [PMID: 31379063 DOI: 10.1111/pan.13703] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 07/07/2019] [Accepted: 07/09/2019] [Indexed: 01/31/2023]
Abstract
Childhood allergy is common, and increasing. Many children are incorrectly labeled as having allergy or adverse drug reactions. This can pose a dilemma for anesthetists and lead to a change in practice or drug selection. We review the pathophysiology of hypersensitivity reactions and the implications for anesthesia of food allergy, atopy, and family history of allergy in children. The epidemiology of anaphylaxis is discussed. We discuss the common triggers of perioperative anaphylaxis in children and explore emerging triggers including chlorhexidine and sugammadex. Accurate data on pediatric perioperative anaphylaxis is limited worldwide, with marked geographic variation. This highlights the need for accurate local, district and/or nationwide incident reporting. The clinical features, diagnosis, and management of anaphylaxis under anesthesia are discussed. We review the process of expert allergy testing following a suspected case of anaphylaxis to guide future safe anesthesia administration. The preoperative consultation is an opportunity for referral for allergy testing to allow de-labeling. This has the potential for improved antibiotic stewardship and more effective treatment with first-line therapeutic agents.
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Affiliation(s)
- Bojana Stepanovic
- Department of Anaesthesia and Pain Medicine, Perth Children's Hospital, Perth, Western Australia, Australia
| | - David Sommerfield
- Department of Anaesthesia and Pain Medicine, Perth Children's Hospital, Perth, Western Australia, Australia.,Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Michaela Lucas
- Medical School, The University of Western Australia, Perth, Western Australia, Australia.,Department of Immunology, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Britta S von Ungern-Sternberg
- Department of Anaesthesia and Pain Medicine, Perth Children's Hospital, Perth, Western Australia, Australia.,Medical School, The University of Western Australia, Perth, Western Australia, Australia.,Telethon Kids Institute, Perth, Western Australia, Australia
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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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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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Anaphylaxis-related mortality in the obstetrical setting: analysis of the French National Confidential Enquiry into Maternal Deaths from 2001 to 2012. Br J Anaesth 2019; 123:e151-e153. [DOI: 10.1016/j.bja.2018.12.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 11/27/2018] [Accepted: 12/19/2018] [Indexed: 11/19/2022] Open
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28
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Garvey LH, Ebo DG, Krøigaard M, Savic S, Clarke R, Cooke P, Dewachter P, Garcez T, Guttormsen AB, Hopkins PM, Hepner DL, Khan DA, Kolawole H, Kopac P, Marshall S, Mertes PM, Platt P, Rose M, Sabato V, Sadleir P, Savic L, Scherer K, Takazawa T, Volcheck GW, Voltolini S, Laguna JJ. The use of drug provocation testing in the investigation of suspected immediate perioperative allergic reactions: current status. Br J Anaesth 2019; 123:e126-e134. [DOI: 10.1016/j.bja.2019.03.018] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 03/09/2019] [Accepted: 03/12/2019] [Indexed: 01/23/2023] Open
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Dardeer A, Shallik N. Perioperative anaphylaxis: A new visit to an old topic. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2019. [DOI: 10.1016/j.tacc.2019.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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30
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Sanan N, Lee J, Baxter C, Jeskey J, Hostoffer R. Delayed and protracted allergic reaction to oral lidocaine. Ann Allergy Asthma Immunol 2019; 123:413-414. [PMID: 30878625 DOI: 10.1016/j.anai.2019.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 02/19/2019] [Accepted: 03/06/2019] [Indexed: 11/19/2022]
Affiliation(s)
- Neha Sanan
- University Hospitals Cleveland Medical Center, Cleveland, Ohio.
| | - Jenny Lee
- Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Christina Baxter
- Nova Southeastern University College of Osteopathic Medicine Davie, Florida
| | - Jack Jeskey
- Lake Erie College of Osteopathic Medicine, Bradenton, Florida
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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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Gonzalez-Estrada A, Archibald T, Dinsmore K, Mosier G, Campbell B, Brown S. Stability of diluted neuromuscular blocking agents utilized in perioperative hypersensitivity evaluation. Allergy 2018; 73:2398-2400. [PMID: 30043977 DOI: 10.1111/all.13576] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Alexei Gonzalez-Estrada
- Division of Allergy and Clinical Immunology; Department of Medicine; East Tennessee State University; Johnson City Tennessee
| | - Timothy Archibald
- Gatton College of Pharmacy at East; Tennessee State University; Johnson City Tennessee
| | - Kristen Dinsmore
- Department of Health Sciences; College of Public Health at East; Tennessee State University; Johnson City Tennessee
| | - Greg Mosier
- Gatton College of Pharmacy at East; Tennessee State University; Johnson City Tennessee
| | - Bethany Campbell
- Department of Biological Sciences; King University; Bristol Tennessee
| | - Stacy Brown
- Gatton College of Pharmacy at East; Tennessee State University; Johnson City Tennessee
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33
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Two probable anaphylactic events during consecutive cranial surgeries. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2018. [DOI: 10.1097/cj9.0000000000000072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Immediate Local Anesthetic Reactions: Too Quick to Point the Finger? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:1224-1225. [DOI: 10.1016/j.jaip.2017.10.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 10/06/2017] [Indexed: 11/24/2022]
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Kleris RS, Keswani A, Lugar P. The Eyes Have It: Eyelid Swelling and Rash in a 79-year-old Woman With Macular Degeneration. ALLERGY & RHINOLOGY 2018; 9:2152656718763385. [PMID: 29977647 PMCID: PMC6028157 DOI: 10.1177/2152656718763385] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction A 79-year-old woman with macular degeneration was referred to the Allergy/Immunology clinic for the evaluation of a potential allergy to anti-vascular endothelial growth factor (anti-VEGF) treatments. The patient developed urticaria and eyelid swelling immediately following a retinal injection of aflibercept, which she had previously tolerated. She previously had allergic reactions following ranibizumab and bevacizumab injections. Injections of anti-VEGF treatments were discontinued given concern for allergy with progression of the patient’s disease. Objective To assess the culprit medication(s) responsible for hypersensitivity reactions following anti-VEGF injections for macular degeneration. Methods Medication records were reviewed for each retinal injection. All medications used in each procedure, including the anti-VEGF therapy (aflibercept), topical anesthetics (tetracaine and proparacaine hydrochloride), and antiseptic (povidine), were evaluated with skin testing. She was additionally tested for alternative anti-VEGF therapies (ranibizumab and bevacizumab) as she was thought to have allergies to these agents by prior history. A test dose challenge was completed for aflibercept, ranibizumab, and bevacizumab. Results Skin prick and intradermal testing were negative to aflibercept, ranibizumab, bevacizumab, and povidine. Intradermal testing was positive to tetracaine and proparacaine hydrochloride. The patient passed test dose challenges to aflibercept, ranibizumab, and bevacizumab. Due to her positive hypersensitivity testing to 2 ester anesthetics, the patient underwent skin prick and intradermal testing to the amide anesthetic, lidocaine. This was negative and the patient tolerated a graded challenge to lidocaine. She was deemed to have an immunoglobulin E (IgE)-mediated hypersensitivity to ester-type local anesthetics. She successfully resumed anti-VEGF therapy with an amide local anesthetic. Conclusions The reason for this consult was the concern for hypersensitivity to a biologic anti-VEGF medication. The culprit allergen, the local anesthetic, could have been overlooked without an assessment of all medications used during the procedure. This case highlights the importance of a thorough allergy evaluation of all medications used during procedures to determine the causative agent. Chief Complaint: Eyelid swelling and rash after ophthalmic procedures for macular degeneration.
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Affiliation(s)
- Renee S Kleris
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Anjeni Keswani
- Department of Medicine, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Patricia Lugar
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina.,Department of Medicine, Duke University Medical Center, Durham, North Carolina
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Han J, Ye YM, Lee S. Epidemiology of drug hypersensitivity reactions using 6-year national health insurance claim data from Korea. Int J Clin Pharm 2018; 40:1359-1371. [PMID: 29611015 DOI: 10.1007/s11096-018-0625-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 03/15/2018] [Indexed: 12/17/2022]
Abstract
Background Drug hypersensitivity reactions (DHRs) constitute a large portion of adverse drug reactions (ADRs), but studies for DHR incidence based on national data are scarce. Objective This study aimed to estimate the incidence and patterns of DHRs in a Korean population and the associated utilization of medical resources using the national claims data. Setting The retrospective cohort study performed using the national insurance claim database of the Health Insurance Review and Assessment (HIRA) in Korea. Methods The International Classification of Disease 10th revision code was used to identify DHRs with 20 drug induced DHR codes. The claim data with a diagnosis of DHR in the 2009-2014 periods were analyzed. Main outcome and measure The annual incidence and the 6-year incidence rates were calculated. Incidence rate coefficients were analyzed by sex, age, and year. DHRs following with visits of emergency department (ED) or intensive care unit (ICU) were assessed for utilization of medical resources and risk of ER or ICU visits by sex and age Results A total of 535,049 patients with 1,083,507 claims were assessed in the HIRA database for 6 years. DHR incidence was high in the elderly. The risk of ED and ICU visit with DHR was also higher in the elderly than in the young [highest relative risk, RR of ED 2.59 (1.65-4.07), ICU 5.04 (2.50-10.18)]. DHRs related to blood were high in the young age. Conclusion Incidence of DHRs in the real-world clinical practice was higher in the elderly and female. Clinical consequence was more severe in the elderly.
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Affiliation(s)
- JaeEun Han
- Division of Clinical Pharmacy, College of Pharmacy, Ajou University, Suwon, Republic of Korea.,Department of Pharmacy, Ajou University Hospital, Suwon, Republic of Korea
| | - Young-Min Ye
- Department of Allergy, College of Medicine, Ajou University, Suwon, Republic of Korea
| | - Sukhyang Lee
- Division of Clinical Pharmacy, College of Pharmacy, Ajou University, Suwon, Republic of Korea. .,Division of Clinical Pharmacy Practice Education, Ajou University Hospital, Suwon, Republic of Korea.
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Müller CSL, Hubner W, Thieme-Ruffing S, Pföhler C, Vogt T, Volk T, Gärtner BC, Bialas P. Pre- and perioperative aspects of dermatosurgery. J Dtsch Dermatol Ges 2017; 15:117-146. [PMID: 28214316 DOI: 10.1111/ddg.13181] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 12/13/2016] [Indexed: 12/12/2022]
Abstract
Dermatosurgery occupies an exceptional position among all surgical disciplines. Above all, this includes the fact that, with very few exceptions, the vast majority of surgical interventions can be performed under local or regional anesthesia, usually in smaller procedure rooms that are spatially separated from larger operating suites. Thus, peri- and postinterventional patient monitoring is the responsibility of the dermatosurgeon and his team. Though inherently smaller, this team still has to observe numerous perioperative requirements that - in larger surgical specialties - would be attended to by a host of various specialists working in concert. Said requirements include hygienic aspects, knowledge concerning pre- and intraoperative patient monitoring, managing surgical site infections, adequate postsurgical pain management, as well as detailed pharmacological knowledge with respect to common local anesthetics and the toxic and allergic reactions associated therewith. Not only does this require interdisciplinary collaboration and shared responsibility for the patient. It also necessitates the development and implementation of quality-oriented and evidence-based guidelines that, in the dermatosurgical setting, usually extend far beyond the scope of the specialty per se. The objective of the present CME article is the condensed presentation of interdisciplinary aspects relating to the most important perioperative issues.
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Affiliation(s)
- Cornelia S L Müller
- Department of Dermatology, Saarland University Medical Center, Homburg/Saar, Germany
| | - Wakiko Hubner
- Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, Saarland University Medical Center, Homburg/Saar, Germany
| | - Sigrid Thieme-Ruffing
- Institute for Medical Microbiology and Hygiene, Saarland University Medical Center, Homburg/Saar, Germany
| | - Claudia Pföhler
- Department of Dermatology, Saarland University Medical Center, Homburg/Saar, Germany
| | - Thomas Vogt
- Department of Dermatology, Saarland University Medical Center, Homburg/Saar, Germany
| | - Thomas Volk
- Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, Saarland University Medical Center, Homburg/Saar, Germany
| | - Barbara C Gärtner
- Institute for Medical Microbiology and Hygiene, Saarland University Medical Center, Homburg/Saar, Germany
| | - Patric Bialas
- Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, Saarland University Medical Center, Homburg/Saar, Germany
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Montañez MI, Mayorga C, Bogas G, Barrionuevo E, Fernandez-Santamaria R, Martin-Serrano A, Laguna JJ, Torres MJ, Fernandez TD, Doña I. Epidemiology, Mechanisms, and Diagnosis of Drug-Induced Anaphylaxis. Front Immunol 2017; 8:614. [PMID: 28611774 PMCID: PMC5446992 DOI: 10.3389/fimmu.2017.00614] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 05/09/2017] [Indexed: 12/14/2022] Open
Abstract
Anaphylaxis is an acute, life-threatening, multisystem syndrome resulting from the sudden release of mediators by mast cells and basophils. Although anaphylaxis is often under-communicated and thus underestimated, its incidence appears to have risen over recent decades. Drugs are among the most common triggers in adults, being analgesics and antibiotics the most common causal agents. Anaphylaxis can be caused by immunologic or non-immunologic mechanisms. Immunologic anaphylaxis can be mediated by IgE-dependent or -independent pathways. The former involves activation of Th2 cells and the cross-linking of two or more specific IgE (sIgE) antibodies on the surface of mast cells or basophils. The IgE-independent mechanism can be mediated by IgG, involving the release of platelet-activating factor, and/or complement activation. Non-immunological anaphylaxis can occur through the direct stimulation of mast cell degranulation by some drugs, inducing histamine release and leading to anaphylactic symptoms. Work-up of a suspected drug-induced anaphylaxis should include clinical history; however, this can be unreliable, and skin tests should also be used if available and validated. Drug provocation testing is not recommended due to the risk of inducing a harmful reaction. In vitro testing can help to confirm anaphylaxis by analyzing the release of mediators such as tryptase or histamine by mast cells. When immunologic mechanisms are suspected, serum-sIgE quantification or the use of the basophil activation test can help confirm the culprit drug. In this review, we will discuss multiple aspects of drug-induced anaphylaxis, including epidemiology, mechanisms, and diagnosis.
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Affiliation(s)
- Maria Isabel Montañez
- Research Laboratory, IBIMA-Regional University Hospital of Malaga-UMA, Málaga, Spain.,Andalusian Center for Nanomedicine and Biotechnology-BIONAND, Málaga, Spain
| | - Cristobalina Mayorga
- Research Laboratory, IBIMA-Regional University Hospital of Malaga-UMA, Málaga, Spain.,Allergy Unit, IBIMA-Regional University Hospital of Malaga-UMA, Málaga, Spain
| | - Gador Bogas
- Allergy Unit, IBIMA-Regional University Hospital of Malaga-UMA, Málaga, Spain
| | - Esther Barrionuevo
- Allergy Unit, IBIMA-Regional University Hospital of Malaga-UMA, Málaga, Spain
| | | | - Angela Martin-Serrano
- Research Laboratory, IBIMA-Regional University Hospital of Malaga-UMA, Málaga, Spain.,Andalusian Center for Nanomedicine and Biotechnology-BIONAND, Málaga, Spain
| | | | - Maria José Torres
- Andalusian Center for Nanomedicine and Biotechnology-BIONAND, Málaga, Spain.,Allergy Unit, IBIMA-Regional University Hospital of Malaga-UMA, Málaga, Spain
| | - Tahia Diana Fernandez
- Research Laboratory, IBIMA-Regional University Hospital of Malaga-UMA, Málaga, Spain
| | - Inmaculada Doña
- Allergy Unit, IBIMA-Regional University Hospital of Malaga-UMA, Málaga, Spain
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Abstract
BACKGROUND The specialty of dermatology relies heavily on local anesthesia for diagnosis and management of skin disease. The appropriate selection, preparation, administration, and monitoring of these medications affect surgical outcome and patient safety and satisfaction. OBJECTIVE To perform a comprehensive literature review of the side effects and risks associated with local anesthetics used in cutaneous surgery. Current recommendations to reduce risk and minimize side effects are reviewed. MATERIALS AND METHODS A comprehensive review of the English-language medical literature search was performed. RESULTS No current review articles of the side effects and risks of local anesthetics were identified. This review serves to discuss local anesthetics commonly used in dermatology and cutaneous surgery along with practical information regarding prevention of adverse outcomes and addressing local and systemic reactions when they arise. CONCLUSION Local anesthetics commonly used in cutaneous surgery have potential risks and side effects. Appropriate selection and utilization of local anesthetics and knowledge of the means to prevent and address these risks can impact surgical outcomes, patient satisfaction and safety, and ultimately patient experience in the dermatology clinic.
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40
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Tacquard C, Collange O, Gomis P, Malinovsky JM, Petitpain N, Demoly P, Nicoll S, Mertes PM. Anaesthetic hypersensitivity reactions in France between 2011 and 2012: the 10th GERAP epidemiologic survey. Acta Anaesthesiol Scand 2017; 61:290-299. [PMID: 28164269 DOI: 10.1111/aas.12855] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 09/25/2016] [Accepted: 12/27/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Immediate hypersensitivity reactions during anaesthesia are rare but potentially life-threatening. The epidemiology changes with time and evolving professional practice, and hence needs to be monitored. Our objective was to follow this epidemiology. METHODS This was a retrospective, observational study in French hospital clinics, conducted by GERAP members (Groupe d'Étude des Réactions Anaphylactoïdes Périopératoires). Consecutive patients seen in allergo-anaesthesia outpatient clinics, who had experienced a hypersensitivity reaction during anaesthesia between 1 January 2011 and 31 December 2012, were included. Demographic data, allergy history, drugs received before the reaction, symptoms of the reaction, results of blood samples (histamine, tryptase, IgE-specific assays), and results of the allergy assessment were recorded. RESULTS The most common causes of allergic reactions were (Neuromuscular Blocking Agents) NMBAs (N = 302; 60.6%), antibiotics (N = 91, 18.2%, Cephalosporin N = 49, 10%) and dyes (N = 27; 5.4%). Latex as an allergic agent was involved in 26 cases (5.2%), hypnotics in 11 cases (2.2%) and opioids in seven cases (1.4%). Of the NMBAs, Rocuronium had the highest proportion of reactions (13.8 reactions/100,000 vials sold) followed by Suxamethonium (13.3/100,000 vials sold). Cisatracurium had the lowest proportion of reactions (0.4/100,000 vials sold). Patients were sensitized to two or more NMBAs in 48.9% of cases and without testing, cross-sensitivity cannot be predicted. CONCLUSIONS When compared with the previous GERAP studies, NMBAs are still the most frequently triggering allergens, with marked differences between individual NMBAs, but they are now followed by antibiotics (of which greater than 50% were cephalosporins) and dyes. Anaesthetists must be aware of the differences between drugs and of the pattern of emerging allergens. For the future of safe anaesthesia, allergy assessment is essential.
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Affiliation(s)
- C. Tacquard
- Department of Anaesthesiology and Intensive Care; Hôpitaux Universitaires de Strasbourg; Strasbourg France
| | - O. Collange
- Department of Anaesthesiology and Intensive Care; Hôpitaux Universitaires de Strasbourg; Strasbourg France
| | - P. Gomis
- Department of Anaesthesiology and Intensive Care; Hôpital Maison Blanche; CHU de Reims; Reims France
| | - J.-M. Malinovsky
- Department of Anaesthesiology and Intensive Care; Hôpital Maison Blanche; CHU de Reims; Reims France
| | - N. Petitpain
- Centre Regional de Pharmacovigilance de Lorraine; CHU de Nancy; Nancy France
| | - P. Demoly
- Department of Pulmonology - Division of Allergy; Hôpital Arnaud de Villeneuve; University Hospital of Montpellier; Montpellier France
- UPMC Paris 06; UMR-S 1136; IPLESP; Equipe EPAR; Sorbonne Universités; Paris France
| | - S. Nicoll
- Department of anaesthesia; Christchurch Hospital; Christchurch New Zealand
| | - P. M. Mertes
- Department of Anaesthesiology and Intensive Care; Hôpitaux Universitaires de Strasbourg; Strasbourg France
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Müller CSL, Hubner W, Thieme-Ruffing S, Pföhler C, Vogt T, Volk T, Gärtner BC, Bialas P. Prä- und perioperative Aspekte der Versorgung dermatochirurgischer Patienten. J Dtsch Dermatol Ges 2017; 15:117-148. [PMID: 28214321 DOI: 10.1111/ddg.13181_g] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 12/13/2016] [Indexed: 12/12/2022]
Abstract
Die Dermatochirurgie nimmt hinsichtlich vieler Punkte eine Sonderstellung unter den operativen Fächern ein. Hierzu gehört in erster Linie die Tatsache, dass bis auf wenige Ausnahmen fast alle Eingriffe traditionell in Lokal- bzw. Regionalanästhesie und oft auch in räumlich-infrastruktureller Trennung von den großen Zentral-Operationssälen stattfinden können. Die peri- und postoperative Überwachung obliegt dabei dem dermatochirurgischen Operationsteam. Das sui generis kleinere OP-Team hat somit eine ganze Reihe perioperativer Notwendigkeiten zu beachten, um die sich in den "großen" chirurgischen Fächern eine Vielzahl verschiedener beteiligter Fachgruppen gemeinsam kümmern. Hierzu gehören neben Hygieneaspekten, Kenntnissen in der Überwachung der Patienten sowie dem Aspekt der surgical site infections auch Fragen zur postoperativen Schmerztherapie sowie detailliertes pharmakologisches Wissen über die zur Anwendung kommenden Lokalanästhetika und das Handling der damit assoziierten toxischen und allergischen Reaktionen. Eine interdisziplinäre Zusammenarbeit und Verantwortung für den Patienten ist notwendig und erfordert die Erarbeitung und Umsetzung qualitätsorientierter und evidenzbasierter Handlungsanweisungen, die im dermatochirurgischen OP-Setting meist weit über das eigentliche Fach hinausgehen. Ziel dieses Weiterbildungsartikels soll die komprimierte Darstellung der genannten fachübergreifenden Standpunkte bezüglich der wichtigsten perioperativen Aspekte sein.
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Affiliation(s)
- Cornelia S L Müller
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum des Saarlandes, Homburg/Saar
| | - Wakiko Hubner
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum des Saarlandes, Homburg/Saar
| | - Sigrid Thieme-Ruffing
- Institut für Medizinische Mikrobiologie und Hygiene, Universitätsklinikum des Saarlandes, Homburg/Saar
| | - Claudia Pföhler
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum des Saarlandes, Homburg/Saar
| | - Thomas Vogt
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum des Saarlandes, Homburg/Saar
| | - Thomas Volk
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum des Saarlandes, Homburg/Saar
| | - Barbara C Gärtner
- Institut für Medizinische Mikrobiologie und Hygiene, Universitätsklinikum des Saarlandes, Homburg/Saar
| | - Patric Bialas
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum des Saarlandes, Homburg/Saar
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Mertes PM, Florvaag E. Anaphylaxis in the operating theatre. Presse Med 2017; 45:750-2. [PMID: 27666588 DOI: 10.1016/j.lpm.2016.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Affiliation(s)
- Paul-Michel Mertes
- Hôpitaux universitaires de Strasbourg, Nouvel hôpital civil, service d'anesthésie-réanimation chirurgicale, 1, place de l'Hôpital, BP 426, 67091 Strasbourg cedex, France.
| | - Erik Florvaag
- Haukeland university hospital, regional centre for asthma, allergy and hypersensitivity, department of occupational medicine, 5021 Bergen, Norway.
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Kvisselgaard AD, Krøigaard M, Mosbech HF, Garvey LH. No cases of perioperative allergy to local anaesthetics in the Danish Anaesthesia Allergy Centre. Acta Anaesthesiol Scand 2017; 61:149-155. [PMID: 27878813 DOI: 10.1111/aas.12833] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 08/30/2016] [Accepted: 10/30/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Local anaesthetics (LA) are often suspected as possible causes of allergic reactions. The Danish Anaesthesia Allergy Centre (DAAC) is the national reference centre for investigation of perioperative allergic reactions. The purpose of this study was to investigate the incidence of IgE-mediated immediate type perioperative allergic reactions to LA. METHODS In the period 2004-2013, a total of 409 patients (244 women/165 men; median age 49 years, range 1-86 years) were investigated in DAAC on suspicion of allergy associated with anaesthesia and surgery. A total of 162 (40%) patients were exposed to one or more LA. Suspected allergy to LA was investigated by prick test, intradermal test and subcutaneous provocation with the suspected drug. Patients with positive skin tests still underwent subcutaneous provocation, as false positive skin tests can occur. RESULTS A total of 203 test series with LA were carried out on 162 patients (89 women/73 men; mean age 49 years, range 2-85 years) with the following drugs: Lidocaine n = 80 (49%), bupivacaine n = 82 (51%), ropivacaine n = 31 (19%) and mepivacaine n = 10 (6%). All 162 patients had negative subcutaneous provocation for all tested LA (95% CI: 0-1.8%). Investigations revealed another allergen in 52 of 162 patients. CONCLUSION None of the 162 patients with suspected perioperative allergic reactions and exposure to LA reacted on subcutaneous provocation with the relevant LA. Thus, no patients have been diagnosed with allergy to LA in DAAC in the period 2004-2013 and allergy to LA must be considered very rare in this population.
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Affiliation(s)
- A. D. Kvisselgaard
- Danish Anaesthesia Allergy Centre; Allergy Clinic; Department of Dermatology and Allergy; Herlev and Gentofte Hospital; University of Copenhagen; Hellerup Denmark
| | - M. Krøigaard
- Danish Anaesthesia Allergy Centre; Allergy Clinic; Department of Dermatology and Allergy; Herlev and Gentofte Hospital; University of Copenhagen; Hellerup Denmark
| | - H. F. Mosbech
- Danish Anaesthesia Allergy Centre; Allergy Clinic; Department of Dermatology and Allergy; Herlev and Gentofte Hospital; University of Copenhagen; Hellerup Denmark
| | - L. H. Garvey
- Danish Anaesthesia Allergy Centre; Allergy Clinic; Department of Dermatology and Allergy; Herlev and Gentofte Hospital; University of Copenhagen; Hellerup Denmark
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McGarry DP, Kim YM, Casselman J, Wenz R, Jhaveri D, Tcheurekdjian H, Hostoffer RW. Ocular desensitization in the face of local anesthetic hypersensitivity. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2016; 5:819-820. [PMID: 27838329 DOI: 10.1016/j.jaip.2016.09.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 09/16/2016] [Accepted: 09/28/2016] [Indexed: 11/25/2022]
Affiliation(s)
- David P McGarry
- Medical Education Department, Akron Children's Hospital, Akron, Ohio.
| | - Yoon Mi Kim
- Department of Allergy and Immunology, University Hospitals, Regional Hospitals, Richmond Heights, Ohio
| | - Jason Casselman
- Department of Allergy and Immunology, University Hospitals, Regional Hospitals, Richmond Heights, Ohio
| | - Robert Wenz
- Vitreo-Retinal Consultants, Painesville, Ohio
| | - Devi Jhaveri
- Allergy/Immunology Associates Inc, Mayfield Heights, Ohio
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Perioperative Hypersensitivity Reactions: Diagnosis, Treatment and Evaluation. CURRENT TREATMENT OPTIONS IN ALLERGY 2016. [DOI: 10.1007/s40521-016-0078-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Takazawa T, Mitsuhata H, Mertes PM. Sugammadex and rocuronium-induced anaphylaxis. J Anesth 2015; 30:290-7. [PMID: 26646837 PMCID: PMC4819478 DOI: 10.1007/s00540-015-2105-x] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Accepted: 11/11/2015] [Indexed: 12/19/2022]
Abstract
Perioperative anaphylaxis is a life-threatening clinical condition that is typically the result of drugs or substances used for anesthesia or surgery. The most common cause of anaphylaxis during anesthesia is reportedly neuromuscular blocking agents. Of the many muscle relaxants that are clinically available, rocuronium is becoming popular in many countries. Recent studies have demonstrated that succinylcholine (but also rocuronium use) is associated with a relatively high rate of IgE-mediated anaphylaxis compared with other muscle relaxant agents. Sugammadex is widely used for reversal of the effects of steroidal neuromuscular blocking agents, such as rocuronium and vecuronium. Confirmed cases of allergic reactions to clinical doses of sugammadex have also been recently reported. Given these circumstances, the number of cases of hypersensitivity to either sugammadex or rocuronium is likely to increase. Thus, anesthesiologists should be familiar with the epidemiology, mechanisms, and clinical presentations of anaphylaxis induced by these drugs. In this review, we focus on the diagnosis and treatment of anaphylaxis to sugammadex and neuromuscular blocking agents. Moreover, we discuss recent studies in this field, including the diagnostic utility of flow cytometry and improvement of rocuronium-induced anaphylaxis with the use of sugammadex.
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Affiliation(s)
- Tomonori Takazawa
- Department of Anesthesiology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, 371-8511, Japan.
| | - Hiromasa Mitsuhata
- Department of Anesthesiology, Juntendo Tokyo Koto Geriatric Medical Center, 3-3-20 Shinsuna, Koto-Ku, Tokyo, 136-0075, Japan
| | - Paul Michel Mertes
- Service d'anesthésie-réanimation chirurgicale, Nouvel hôpital civil, hôpitaux universitaires de Strasbourg, 1, place de l'Hôpital, BP 426, 67091, Strasbourg Cedex, France
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Laroche D, Gomis P, Malinovsky JM, Mertes PM. In Reply. Anesthesiology 2015; 122:714-5. [DOI: 10.1097/aln.0000000000000585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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