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Salehin S, Kumar A, Harsell N, Salim H, Hussain SA, Kueht M, Mujtaba MA. A case series of perioperative anaphylaxis to cefazolin during kidney transplant and review of literature. Transpl Immunol 2022; 75:101720. [PMID: 36126905 DOI: 10.1016/j.trim.2022.101720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 09/11/2022] [Accepted: 09/13/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Intraoperative anaphylaxis is a life threatening and multiorgan system hypersensitivity reaction that frequently leads to cessation of operations. Despite the incidence of Cefazolin allergy being on the rise, the cases of anaphylaxis to Cefazolin during surgeries and its management are seldom reported. CASE PRESENTATION We present two patients with no known beta-lactam allergy and end stage kidney disease who received perioperative intravenous Cefazolin for planned deceased kidney transplant surgery at our academic medical center. Both patients developed anaphylaxes approximately three minutes following the administration of the antibiotic and experienced severe, refractory hypotension that required the use of vasopressors. The severity of the anaphylactic reactions resulted in the cessation of the transplant operation and multiple days of intensive care unit admission. CONCLUSION Peri-or intraoperative anaphylaxis to Cefazolin is on the rise and its consequences in transplant candidates are even more dire given the pre-existing end organ failure, financial burden for health care system, potential loss of donor organs, and emotional burden for recipients and their families. These are the first two cases of reported Cefazolin-induced anaphylaxis that actually resulted in aborting the kidney transplant operation. In addition, cases of previously reported Type 1 hypersensitivity to Cefazolin as prophylaxis for operations were reviewed and the allergy workups were discussed.
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Affiliation(s)
- Salman Salehin
- Internal Medicine, University of Texas Medical Branch, Galveston, TX, United States.
| | - Anand Kumar
- Nephrology, University of Texas Medical Branch, Galveston, TX, United States
| | - Nantian Harsell
- School of Medicine, University of Texas Medical Branch, Galveston, TX, United States
| | - Hamza Salim
- Internal Medicine, University of Texas Medical Branch, Galveston, TX, United States
| | - Syed A Hussain
- Nephrology, University of Texas Medical Branch, Galveston, TX, United States
| | - Michael Kueht
- Transplant Surgery, University of Texas Medical Branch, Galveston, TX, United States
| | - Muhammad A Mujtaba
- Nephrology, University of Texas Medical Branch, Galveston, TX, United States
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Bahal S, Zinser E, Morrison C, Msonthi A, Pillai P, Ali FR. Identification of factors affecting the outcome of General Anaesthetic Allergy Testing. Clin Exp Allergy 2020; 50:977-980. [PMID: 32484979 DOI: 10.1111/cea.13674] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 05/06/2020] [Accepted: 05/17/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Sameer Bahal
- Allergy Service, Respiratory Department, St Bartholomew's Hospital, London, UK
| | - Emily Zinser
- Allergy Service, Respiratory Department, St Bartholomew's Hospital, London, UK
| | - Cynthia Morrison
- Allergy Service, Respiratory Department, St Bartholomew's Hospital, London, UK
| | - Angela Msonthi
- Allergy Service, Respiratory Department, St Bartholomew's Hospital, London, UK
| | - Prathap Pillai
- Allergy Service, Respiratory Department, St Bartholomew's Hospital, London, UK
| | - F Runa Ali
- Allergy Service, Respiratory Department, St Bartholomew's Hospital, London, UK
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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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Abstract
General anaesthesia for the patient with a history of anaesthesia-related anaphylaxis is challenging. Precautions against anaphylaxis and the use of skin test negative drugs can reduce but not eliminate the risk. In the majority of such cases, subsequent anaesthesia is uneventful. However, the absence of a clearly identified triggering agent increases the difficulties facing the anaesthetist. We present a case of anaphylaxis to cisatracurium following a negative skin test.
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Affiliation(s)
- B A Fraser
- Department of Anaesthesia and Pain Management, Alfred Hospital, Melbourne, Victoria
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Kuhlen JL, Camargo CA, Balekian DS, Blumenthal KG, Guyer A, Morris T, Long A, Banerji A. Antibiotics Are the Most Commonly Identified Cause of Perioperative Hypersensitivity Reactions. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2016; 4:697-704. [PMID: 27039234 DOI: 10.1016/j.jaip.2016.02.008] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 02/15/2016] [Accepted: 02/19/2016] [Indexed: 01/13/2023]
Abstract
BACKGROUND Hypersensitivity reactions (HSRs) during the perioperative period are unpredictable and can be life threatening. Prospective studies for the evaluation of perioperative HSRs are lacking, and data on causative agents vary between different studies. OBJECTIVE The objective of this study was to prospectively determine the success of a comprehensive allergy evaluation plan for patients with HSRs during anesthesia, including identification of a causative agent and outcomes during subsequent anesthesia exposure. METHODS All patients referred for a perioperative HSR between November 2013 and March 2015, from a Boston teaching hospital, were evaluated using a standardized protocol with skin testing (ST) within 6 months of HSR. Comprehensive allergy evaluation included collection of patient information, including characteristics of HSR during anesthesia. We reviewed the results of ST and/or test doses for all potential causative medications Event-related tryptase levels were reviewed when available. RESULTS Over 17 months, 25 patients completed the comprehensive allergy evaluation. Fifty-two percent (13 of 25) were female with a median age of 52 (interquartile range 43-66) years. The most frequently observed HSR systems were cutaneous (68%), cardiovascular (64%), and pulmonary (24%). A culprit drug, defined as a positive ST, was identified in 36% (9 of 25) of patients. The most common agent identified was cefazolin (6 of 9). After our comprehensive evaluation and management plan, 7 (7 of 8, 88%) patients tolerated subsequent anesthesia. CONCLUSIONS Cefazolin was the most commonly identified cause of a perioperative HSR in our study population. Skin testing patients within 6 months of a perioperative HSR may improve the odds of finding a positive result. Tolerance of subsequent anesthesia is generally achieved in patients undergoing our comprehensive evaluation.
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Affiliation(s)
- James L Kuhlen
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass.
| | - Carlos A Camargo
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Mass
| | - Diana S Balekian
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass; Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Mass
| | - Autumn Guyer
- Division of Allergy and Inflammation, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Mass; Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California San Francisco, San Francisco, Calif
| | - Theresa Morris
- Department of Anesthesia, Massachusetts General Hospital, Boston, Mass
| | - Aidan Long
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass
| | - Aleena Banerji
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass
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Berrío Valencia MI. Perioperative anaphylaxis. Braz J Anesthesiol 2015; 65:292-7. [PMID: 26123146 DOI: 10.1016/j.bjane.2014.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Accepted: 09/08/2014] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Anaphylaxis remains one of the potential causes of perioperative death, being generally unanticipated and quickly progress to a life threatening situation. A narrative review of perioperative anaphylaxis is performed. CONTENT The diagnostic tests are primarily to avoid further major events. The mainstays of treatment are adrenaline and intravenous fluids. CONCLUSION The anesthesiologist should be familiar with the proper diagnosis, management and monitoring of perioperative anaphylaxis.
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Abstract
Chlorhexidine is an antiseptic agent, commonly used, in many different preparations, and for multiple purposes. Despite its superior antimicrobial properties, chlorhexidine is a potentially allergenic substance. The following is a review of the current evidence-based knowledge of allergic reactions to chlorhexidine associated with surgical and interventional procedures.
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Affiliation(s)
- Claude Abdallah
- Division of Anesthesiology, The George Washington University Medical Center, Children's National Medical Center, Washington, D. C. 20010-2970, USA
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Berrío Valencia MI. [Perioperative anaphylaxis]. Rev Bras Anestesiol 2015; 65:292-7. [PMID: 25935855 DOI: 10.1016/j.bjan.2014.09.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Accepted: 09/08/2014] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Anaphylaxis remains one of the potential causes of perioperative death, being generally unanticipated and quickly progressing to a life-threatening situation. A review of perioperative anaphylaxis is performed. CONTENT The diagnostic tests are important mainly to avoid further major events. The mainstays of treatment are adrenaline and intravenous fluids. CONCLUSION The anesthesiologist should be familiar with the proper diagnosis, management and monitoring of perioperative anaphylaxis.
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Abstract
The incidence of anaphylaxis during anesthesia has been reported to range from 1 in 4000 to 1 in 25,000. Anaphylaxis during anesthesia can present as cardiovascular collapse, airway obstruction, and/or skin manifestation. It can be difficult to differentiate between immune and nonimmune mast cell-mediated reactions and pharmacologic effects from the variety of medications administered during general anesthesia. In addition, cutaneous manifestations of anaphylaxis are less likely to be apparent when anaphylaxis occurs in this setting. The evaluation of IgE-mediated reactions to medications used during anesthesia can include skin testing to a variety of anesthetic agents. Specifically, thiopental allergy has been documented by skin tests. Neuromuscular blocking agents such as succinylcholine can cause nonimmunologic histamine release, but there have also been reports of IgE-mediated reactions in some patients. Reactions to opioid analgesics are usually caused by direct mast cell mediator release rather than IgE-dependent mechanisms. Antibiotics that are administered perioperatively can cause immunologic or nonimmunologic reactions. Protamine can cause severe systemic reactions through IgE-mediated or nonimmunologic mechanisms. Blood transfusions can elicit a variety of systemic reactions, some of which might be IgE-mediated or mediated through other immunologic mechanisms. The management of anaphylactic reactions that occur during general anesthesia is similar to the management of anaphylaxis in other situations.
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Affiliation(s)
- Shrikant Mali
- MDS Oral and Maxillofacial Surgery, Sr Lecturer, Department of Oral and Maxillofacial Surgery CSMSS Dental College, Aurangabad, India
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Nassiri M, Babina M, Dölle S, Edenharter G, Ruëff F, Worm M. Ramipril and metoprolol intake aggravate human and murine anaphylaxis: Evidence for direct mast cell priming. J Allergy Clin Immunol 2015; 135:491-9. [DOI: 10.1016/j.jaci.2014.09.004] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Revised: 09/02/2014] [Accepted: 09/08/2014] [Indexed: 11/24/2022]
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Guyer AC, Saff RR, Conroy M, Blumenthal KG, Camargo CA, Long AA, Banerji A. Comprehensive Allergy Evaluation Is Useful in the Subsequent Care of Patients with Drug Hypersensitivity Reactions During Anesthesia. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2015; 3:94-100. [DOI: 10.1016/j.jaip.2014.11.011] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Revised: 11/14/2014] [Accepted: 11/17/2014] [Indexed: 10/24/2022]
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Saito M, Abe M, Furukawa T, Yagi M, Koike Y, Wakasugi Y, Tabuchi N, Uno K. Examination of patients suspected as having hypersensitivity to iodinated contrast media with leukocyte migration test. Biol Pharm Bull 2014; 37:1750-7. [PMID: 25366481 DOI: 10.1248/bpb.b14-00346] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
In vivo tests may be used for the diagnosis of allergy to iodinated contrast media (ICM); however, the tests do not provide definitive diagnosis and are associated with risks for patients. Diagnoses based on in vitro tests are limited, and there are almost no relevant studies. Herein, the authors examined involvement of allergic reaction from a multilateral standpoint in 39 patients suspected of having ICM allergies using leukocyte migration test (LMT). The positive rate of LMT was 44%. A comparison with the positive rate of LMT in drugs other than ICM (74%) indicated 30% difference, which was significantly low value, suggesting that there is poor involvement of these drugs in the allergic reaction. In LMT positives, 76% of hypersensitivity reactions were skin rash mainly erythema, and 18% was anaphylactic reactions. Cases considered as non-immediate hypersensitivity accounted for about 4 times as many as immediate-type hypersensitivity. In examination of relevancy between a history of drugs or food allergies, the incidence of ICM allergies was 35%. There is a high possibility that these adverse reactions were caused by pseudoallergy to drug. It was suggested that most hypersensitivity reactions were skin rash related to non-immediate hypersensitivity, and approximately 20% of the reaction was immediate anaphylactic reaction. Therefore attention should be paid not only to immediate-type hypersensitivity but also delayed reactions. Moreover, it was considered that patients with past history of drug or food allergies have a high potential for manifestation of the reactions.
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Affiliation(s)
- Mikio Saito
- Laboratory of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Niigata University of Pharmacy and Life Sciences
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Fineman SM. Optimal treatment of anaphylaxis: antihistamines versus epinephrine. Postgrad Med 2014; 126:73-81. [PMID: 25141245 DOI: 10.3810/pgm.2014.07.2785] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Anaphylaxis is a rapid, systemic, often unanticipated, and potentially life-threatening immune reaction occurring after exposure to certain foreign substances. The main immunologic triggers include food, insect venom, and medications. Multiple immunologic pathways underlie anaphylaxis, but most involve immune activation and release of immunomodulators. Anaphylaxis can be difficult to recognize clinically, making differential diagnosis key. The incidence of anaphylaxis has at least doubled during the past few decades, and in the United States alone, an estimated 1500 fatalities are attributed to anaphylaxis annually. The increasing incidence and potentially life-threatening nature of anaphylaxis coupled with diagnostic challenges make appropriate and timely treatment critical. Epinephrine is universally recommended as the first-line therapy for anaphylaxis, and early treatment is critical to prevent a potentially fatal outcome. Despite the evidence and guideline recommendations supporting its use for anaphylaxis, epinephrine remains underused. Data indicate that antihistamines are more commonly used to treat patients with anaphylaxis. Although histamine is involved in anaphylaxis, treatment with antihistamines does not relieve or prevent all of the pathophysiological symptoms of anaphylaxis, including the more serious complications such as airway obstruction, hypotension, and shock. Additionally, antihistamines do not act as rapidly as epinephrine; maximal plasma concentrations are reached between 1 and 3 hours for antihistamines compared with < 10 minutes for intramuscular epinephrine injection. This demonstrates the need for improved approaches to educate physicians and patients regarding the appropriate treatment of anaphylaxis.
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Affiliation(s)
- Stanley M Fineman
- Adjunct Associate Professor, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA; Atlanta Allergy and Asthma Clinic, Marietta, GA.
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Wölbing F, Fischer J, Köberle M, Kaesler S, Biedermann T. About the role and underlying mechanisms of cofactors in anaphylaxis. Allergy 2013; 68:1085-92. [PMID: 23909934 DOI: 10.1111/all.12193] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2013] [Indexed: 12/20/2022]
Abstract
Anaphylaxis is the systemic and most severe presentation of type I allergy. A number of conditions were identified that modulate the onset of anaphylaxis such as co- or augmentation factors, which significantly lower the allergen dose necessary for triggering anaphylaxis. Next to physical exercise or alcohol consumption, co-administration of nonsteroidal anti-inflammatory drugs (NSAID) or concomitant infectious diseases are well-documented cofactors of anaphylaxis. Registries for anaphylaxis document a role for cofactors in about 30% of anaphylactic reactions. Some disease entities such as 'wheat-dependent exercise-induced anaphylaxis' (WDEIA) are explicitly characterized by elicitation of anaphylaxis only in the presence of at least one such cofactor. Using WDEIA as a model disease, studies demonstrated that exercise increases skin prick test reactivity to and bioavailability of the allergen. Additional data indicate that alcohol consumption and NSAID administration display similar effects. Modulation of the cellular activation threshold is another mechanism underlying cofactor-induced anaphylaxis, most likely also functional when infectious diseases orchestrate elicitation of anaphylaxis. Cofactors are increasingly accepted to play a fundamental role in eliciting anaphylaxis. Consequently, to improve patient management modalities, a better understanding of the underlying mechanisms is warranted. This review aims to update clinicians and clinical scientists on recent developments.
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Affiliation(s)
- F. Wölbing
- Department of Dermatology; Eberhard-Karls-University of Tübingen; Tübingen; Germany
| | - J. Fischer
- Department of Dermatology; Eberhard-Karls-University of Tübingen; Tübingen; Germany
| | - M. Köberle
- Department of Dermatology; Eberhard-Karls-University of Tübingen; Tübingen; Germany
| | - S. Kaesler
- Department of Dermatology; Eberhard-Karls-University of Tübingen; Tübingen; Germany
| | - T. Biedermann
- Department of Dermatology; Eberhard-Karls-University of Tübingen; Tübingen; Germany
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Mertes PM, Karila C, Demoly P, Auroy Y, Ponvert C, Lucas MM, Malinovsky JM. [What is the reality of anaphylactoid reactions during anaesthesia? Classification, prevalence, clinical features, drugs involved and morbidity and mortality]. ACTA ACUST UNITED AC 2011; 30:223-39. [PMID: 21353759 DOI: 10.1016/j.annfar.2011.01.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- P-M Mertes
- Service d'anesthésie-réanimation chirurgicale, hôpital Central, CHU de Nancy, 29 avenue de Lattre-de-Tassigny, Nancy cedex, France.
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World allergy organization guidelines for the assessment and management of anaphylaxis. World Allergy Organ J 2011; 4:13-37. [PMID: 23268454 PMCID: PMC3500036 DOI: 10.1097/wox.0b013e318211496c] [Citation(s) in RCA: 499] [Impact Index Per Article: 38.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The illustrated World Allergy Organization (WAO) Anaphylaxis Guidelines were created in response to absence of global guidelines for anaphylaxis. Uniquely, before they were developed, lack of worldwide availability of essentials for the diagnosis and treatment of anaphylaxis was documented. They incorporate contributions from more than 100 allergy/immunology specialists on 6 continents. Recommendations are based on the best evidence available, supported by references published to the end of December 2010. The Guidelines review patient risk factors for severe or fatal anaphylaxis, co-factors that amplify anaphylaxis, and anaphylaxis in vulnerable patients, including pregnant women, infants, the elderly, and those with cardiovascular disease. They focus on the supreme importance of making a prompt clinical diagnosis and on the basic initial treatment that is urgently needed and should be possible even in a low resource environment. This involves having a written emergency protocol and rehearsing it regularly; then, as soon as anaphylaxis is diagnosed, promptly and simultaneously calling for help, injecting epinephrine (adrenaline) intramuscularly, and placing the patient on the back or in a position of comfort with the lower extremities elevated. When indicated, additional critically important steps include administering supplemental oxygen and maintaining the airway, establishing intravenous access and giving fluid resuscitation, and initiating cardiopulmonary resuscitation with continuous chest compressions. Vital signs and cardiorespiratory status should be monitored frequently and regularly (preferably, continuously). The Guidelines briefly review management of anaphylaxis refractory to basic initial treatment. They also emphasize preparation of the patient for self-treatment of anaphylaxis recurrences in the community, confirmation of anaphylaxis triggers, and prevention of recurrences through trigger avoidance and immunomodulation. Novel strategies for dissemination and implementation are summarized. A global agenda for anaphylaxis research is proposed.
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Pinnobphun P, Buranapraditkun S, Kampitak T, Hirankarn N, Klaewsongkram J. The diagnostic value of basophil activation test in patients with an immediate hypersensitivity reaction to radiocontrast media. Ann Allergy Asthma Immunol 2011; 106:387-93. [PMID: 21530870 DOI: 10.1016/j.anai.2010.12.020] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2010] [Revised: 12/22/2010] [Accepted: 12/28/2010] [Indexed: 11/30/2022]
Abstract
BACKGROUND No available test diagnoses allergic reactions to radiocontrast media (RCM). The basophil activation test (BAT) has been introduced for the diagnosis of both immunoglobulin (Ig) E and non-IgE-dependent mast cell degranulation, but its value to diagnose immediate RCM reactions is still unknown. OBJECTIVE This study aims to evaluate the diagnostic value of BAT in immediate RCM hypersensitivity. METHODS The BATs were performed in 26 patients with immediate RCM reactions and in 43 specimens from healthy volunteers. The sample's whole blood was incubated with the responsible RCM and % activated (CD63+/CCR3+) basophils were analyzed by flow cytometry. Receiver operating characteristics (ROC) curve analysis was performed to calculate the optimal cutoff value of activated basophils to diagnose patients with RCM hypersensitivity. RESULTS The incubation of blood with RCM yielded significantly higher activated basophil percentages in patients with a history of immediate RCM reactions than in normal controls with both 1:100 and 1:10 dilutions (13.11% vs. 2.71%, P value = .01; and 19.23% vs. 3.73%, P = .001, respectively). Both % activated basophils and stimulation index (SI) had acceptable discrimination powers to diagnose RCM hypersensitivity. The area under the curve was 0.79 (95% CI 0.67-0.91, P = .000) by using SI as the diagnostic criteria with 1:100 dilution of RCM. The specificity of the test ranged from 88.4% to 100%. CONCLUSION Our study demonstrated the potential of BAT as a diagnostic tool for an immediate RCM hypersensitivity, particularly as a confirmation test. Further studies are required to confirm the test accuracy and identify a patient's predisposing factors.
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Affiliation(s)
- Panwas Pinnobphun
- Medical Microbiology, Interdisciplinary Program, Graduate School Chulalongkorn University, Bangkok, Thailand
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Eberli D, Rodriguez S, Atala A, Yoo JJ. In vivo evaluation of acellular human dermis for abdominal wall repair. J Biomed Mater Res A 2010; 93:1527-38. [PMID: 20014294 DOI: 10.1002/jbm.a.32636] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Limitations of synthetic biomaterials for abdominal wall repair have led investigators to seek naturally derived matrices, such as human acellular dermis, because of their excellent biocompatibility and their ability to naturally interface with host tissues with minimal tissue response. In this study, we investigated two different biomaterials derived from human dermis (FlexHD acellular dermis and FlexHD acellular dermis-thick) in a rabbit abdominal hernia repair model. One quarter of the abdominal wall was replaced with each biomaterial, and the animals were followed for up to 24 weeks. Rabbit hernias repaired with AlloDerm, a commercially available acellular dermal matrix, and sham operated animals served as controls. Retrieved samples of these implants were assessed grossly and histologically. Collagen production measurements and tension studies were performed. FlexHD acellular dermis, FlexHD acellular dermis-thick, and AlloDerm maintained their strength in the rabbit hernia repair model with no incidence of hernia formation or bowel adhesion. The exact size measurements at 24 weeks were 217.0 +/- 20.9% for FlexHD acellular dermis, 200.8 +/- 23.5% for FlexHD acellular dermis-thick, and 209.7 +/- 32.9% for AlloDerm. Macroscopic and microscopic evaluation showed excellent integration and tissue formation. All biomaterials studied harbored cells that produced new collagen fibers, and a six-fold increase in these fibers was observed at 24 weeks. This study shows that acellular biomaterials derived from human dermis are suitable for abdominal hernia repair.
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Affiliation(s)
- Daniel Eberli
- Wake Forest Institute for Regenerative Medicine, Medical Center Boulevard, Winston Salem, North Carolina 27157, USA
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Lieberman P, Nicklas RA, Oppenheimer J, Kemp SF, Lang DM, Bernstein DI, Bernstein JA, Burks AW, Feldweg AM, Fink JN, Greenberger PA, Golden DBK, James JM, Kemp SF, Ledford DK, Lieberman P, Sheffer AL, Bernstein DI, Blessing-Moore J, Cox L, Khan DA, Lang D, Nicklas RA, Oppenheimer J, Portnoy JM, Randolph C, Schuller DE, Spector SL, Tilles S, Wallace D. The diagnosis and management of anaphylaxis practice parameter: 2010 update. J Allergy Clin Immunol 2010; 126:477-80.e1-42. [PMID: 20692689 DOI: 10.1016/j.jaci.2010.06.022] [Citation(s) in RCA: 455] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2009] [Revised: 04/27/2010] [Accepted: 06/08/2010] [Indexed: 11/19/2022]
Abstract
These parameters were developed by the Joint Task Force on Practice Parameters, representing the American Academy of Allergy, Asthma & Immunology (AAAAI); the American College of Allergy, Asthma & Immunology (ACAAI); and the Joint Council of Allergy, Asthma and Immunology. The AAAAI and the ACAAI have jointly accepted responsibility for establishing "The Diagnosis and Management of Anaphylaxis Practice Parameter: 2010 Update." This is a complete and comprehensive document at the current time. The medical environment is a changing environment, and not all recommendations will be appropriate for all patients. Because this document incorporated the efforts of many participants, no single individual, including those who served on the Joint Task Force, is authorized to provide an official AAAAI or ACAAI interpretation of these practice parameters. Any request for information about or an interpretation of these practice parameters by the AAAAI or ACAAI should be directed to the Executive Offices of the AAAAI, the ACAAI, or the Joint Council of Allergy, Asthma and Immunology. These parameters are not designed for use by pharmaceutical companies in drug promotion.
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Affiliation(s)
- Phillip Lieberman
- JointCouncil of Allergy, Asthma&Immunology, 50NBrockway St, #3-3, Palatine, IL 60067, USA.
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Abstract
Anaphylaxis in the setting of general anesthesia is a rare but potentially lethal event. The investigation of severe reactions is important for confirming the clinical diagnosis and identifying likely causative agents and safe agents that may be used in the future. Many comprehensive reports have described the testing protocol of individual specialized units, whereas there has been no standardization of testing techniques or formal assessment of these tests' diagnostic accuracy. We review the literature with reference to the recently published standards for reporting of diagnostic accuracy (STARD) and make recommendations for future studies of diagnostic accuracy in the field.
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Bae YJ, Park CS, Lee JK, Jeong E, Kim TB, Cho YS, Moon HB. A case of anaphylaxis to chlorhexidine during digital rectal examination. J Korean Med Sci 2008; 23:526-8. [PMID: 18583893 PMCID: PMC2526523 DOI: 10.3346/jkms.2008.23.3.526] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Chlorhexidine is widely used as an antiseptic and disinfectant in medical and nonmedical environments. Although the sensitization rate seems to be low, its ubiquitous use raises the possibility of sensitization in many patients and medical care workers. We describe a patient with anaphylaxis during digital rectal examination with chlorhexidine jelly. Urticaria, angioedema, dyspnea, and hypotension developed within a few minutes of the rectal examination. The patient fully recovered after treatment with epinephrine and corticosteroids. Skin tests for chlorhexidine were undertaken 5 weeks later, showing positive prick and intradermal skin tests. Within 30 min of the skin test, the patient complained of febrile sensation, chest tightness, angioedema, and urticaria on the face and trunk. An enzyme allergosorbent test for latex was negative. We present this case to alert clinicians about hypersensitivity to chlorhexidine that could potentially be life-threatening. We suggest that chlorhexidine should be recognized as a causative agent of anaphylaxis during procedural interventions.
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Affiliation(s)
- Yun-Jeong Bae
- Division of Allergy and Clinical Immunology, Department of Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chan Sun Park
- Division of Allergy and Clinical Immunology, Department of Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Keun Lee
- Division of Allergy and Clinical Immunology, Department of Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eunheui Jeong
- Division of Allergy and Clinical Immunology, Department of Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae-Bum Kim
- Division of Allergy and Clinical Immunology, Department of Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - You Sook Cho
- Division of Allergy and Clinical Immunology, Department of Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hee-Bom Moon
- Division of Allergy and Clinical Immunology, Department of Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Bernstein IL, Li JT, Bernstein DI, Hamilton R, Spector SL, Tan R, Sicherer S, Golden DBK, Khan DA, Nicklas RA, Portnoy JM, Blessing-Moore J, Cox L, Lang DM, Oppenheimer J, Randolph CC, Schuller DE, Tilles SA, Wallace DV, Levetin E, Weber R. Allergy diagnostic testing: an updated practice parameter. Ann Allergy Asthma Immunol 2008; 100:S1-148. [PMID: 18431959 DOI: 10.1016/s1081-1206(10)60305-5] [Citation(s) in RCA: 291] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Abstract
Correct management of anaphylaxis during anaesthesia requires a multidisciplinary approach with prompt recognition and treatment of the acute event by the attending anaesthesiologist, and subsequent determination of the responsible agent(s) with strict avoidance of subsequent administration of all incriminated and/or cross-reacting compounds. However, correct identification of the causative compound(s) and safe alternatives is not always straightforward and, too often, not done. This review is not intended to discuss acute management of anaesthesia-related anaphylaxis but summarizes the major causes of anaphylaxis during anaesthesia and the diagnostic approach of this rare but potentially life-threatening complication. Apart from general principles about the diagnostic approach, history taking and importance of tryptase quantification, more specific confirmatory diagnostic procedures are organized on the basis of the major causes of perioperative anaphylactic reactions.
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Affiliation(s)
- D G Ebo
- Department of Immunology, Allergology and Rheumatology, University of Antwerp, Antwerpen, Belgium
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Abstract
General anesthesia and anaphylaxis cause profound physiologic changes. When both occur simultaneously, it is often difficult to recognize and identify the medication or product responsible for the latter. Following such an event, the proper assessment, diagnosis, and recommendations are essential to prevent future reactions. This article reviews the more common causes of anaphylaxis during anesthesia.
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Affiliation(s)
- Thomas Chacko
- University of South Florida College of Medicine, 13000 Bruce B. Downs Boulevard, VAR 111D, Tampa, FL 33612, USA
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Kim TH, Cho SJ, Kim HJ, Noh GJ. Chlorhexidine Anaphylaxis after Urethral Catheterization during Anesthesia - A case report -. Korean J Anesthesiol 2007. [DOI: 10.4097/kjae.2007.52.1.104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Tae Hee Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea
| | - Suk Ju Cho
- Department of Anesthesiology and Pain Medicine, Gangneung Asan Hospital, College of Medicine, University of Ulsan, Gangneung, Korea
| | - Hye Jin Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea
| | - Gyu Jeong Noh
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea
- Department of Clinical Pharmacology and Therapeutics, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea
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Chiou CS, Lin SM, Lin SP, Chang WG, Chan KH, Ting CK. Clindamycin-induced anaphylactic shock during general anesthesia. J Chin Med Assoc 2006; 69:549-51. [PMID: 17116619 DOI: 10.1016/s1726-4901(09)70327-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Clindamycin-related anaphylactic reaction is rarely reported. We report a male patient with buccal cancer who was undergoing radical neck dissection when life-threatening anaphylactic shock developed soon after intravenous infusion of clindamycin. Immediate cardiopulmonary resuscitation was performed, and the patient recovered uneventfully. Perioperative anaphylactic shock is a serious problem due to the difficulty of judgment and potentially disastrous outcome. Immediate diagnosis and halting of drug infusion should be the first actions taken.
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Affiliation(s)
- Chiuan-Shiou Chiou
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan
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31
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Ferrarini A, Baggi M, Flückiger R, Bianchetti MG. Intraoperative anaphylaxis to a chlorhexdine polymer in childhood. Paediatr Anaesth 2006; 16:705. [PMID: 16719897 DOI: 10.1111/j.1460-9592.2006.01889.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Freiler JF, Steel KE, Hagan LL, Rathkopf MM, Roman-Gonzalez J. Intraoperative anaphylaxis to bacitracin during pacemaker change and laser lead extraction. Ann Allergy Asthma Immunol 2005; 95:389-93. [PMID: 16279570 DOI: 10.1016/s1081-1206(10)61158-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Bacitracin is widely used in operating rooms to soak implants, irrigate compound fractures, and apply to surgical incisions. However, bacitracin is a known sensitizer and causes not only allergic contact dermatitis but also anaphylaxis. OBJECTIVE To describe a 72-year-old woman with anaphylaxis after irrigation and packing of an infected pacemaker pocket with a bacitracin solution. METHODS Skin prick testing to bacitracin and latex; serum tryptase, serum histamine, serum IgE to latex, and serial cardiac enzyme measurements; blood cultures, transthoracic echocardiograms, and venograms were performed to characterize the reaction. RESULTS Six hours after the anaphylactic event, the patient had an elevated serum tryptase level of 49 ng/mL (reference range, 2-10 ng/mL), which normalized the next morning. She had immediate-type skin prick test reactions to full-strength bacitracin ointment (500 U/g) and bacitracin solution (150 U/mL). Serum IgE level to latex was undetectable, and results of skin testing to latex were negative. CONCLUSIONS To our knowledge, this is the first case report of anaphylaxis to bacitracin during pacemaker surgery. This case illustrates that intraoperative anaphylaxis to bacitracin can be life-threatening.
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Affiliation(s)
- John F Freiler
- Department of Allergy/Immunology, Wilford Hall Medical Center, Lackland AFB, Texas 78236, USA.
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Current World Literature. Curr Opin Allergy Clin Immunol 2005. [DOI: 10.1097/01.all.0000175939.68435.7e] [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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