Investigation of perioperative hypersensitivity reactions: an update

Epidemiology and Triggers of Severe Perioperative Anaphylaxis: An 8-Year Single-Center Study

OBJECTIVE

To determine the features, rescue measures, outcomes, re-allergic reactions, and independent risk factors associated with severe anaphylaxis during surgery.

DESIGN

Instances of severe perioperative anaphylaxis were identified through perioperative electronic records, adverse event reporting records, and surveys of anesthesiologists. Confirmed cases were randomly matched 4:1 with control cases on the same operation day. Patient risk factors, surgery type, anesthetic technique, and perioperative medications, fluids, and blood transfusions were given in instances of severe perioperative anaphylaxis were compared with control cases.

SETTING

A tertiary hospital in China.

PATIENTS

All patients undergoing surgery and anesthesia in the operating room from January 2014 to February 2022.

MEASUREMENTS

Incidence and the independent risk factors for severe perioperative anaphylaxis.

MAIN RESULTS

Ninety-seven patients experienced severe perioperative allergic responses during the 266,033 surgeries performed, with an incidence rate of 3.6 per 10,000. Three of 97 anaphylaxis patients experienced a severe allergic reaction again during the second surgery. The nested case-control study revealed that the independent triggers during surgery were allergy history (odds ratio 5.23; 95% confidence interval [CI], 2.35-11.68; p < 0.001), cisatracurium use (odds ratio 5.03; 95% CI, 1.22-20.70; p < 0.001), hydroxyethyl starch 130/0.4 use (odds ratio 5.36; 95% CI, 2.99-9.60; p =0.025), and allogeneic plasma (odds ratio 11.02; 95% CI, 3.78-35.95; p < 0.001).

CONCLUSIONS

Perioperative severe anaphylaxis is a rare but life-threatening complication. Previous allergic history, cisatracurium, hydroxyethyl starch 130/0.4, and allogeneic plasma may be the independent triggers. Early diagnosis of anaphylaxis and the timely administration of epinephrine are critical to allergic treatment. Avoiding exposure to allergens is effective for preventing severe allergic responses and the efficacy of glucocorticoids and antihistamines is controversial.

[Drug allergy: Fundamental aspects in diagnosis and treatment.]

BACKGROUND

Any substance used as a treatment for any disease can produce harmful or unpleasant events called adverse drug reactions (ADRs). They are due to inherent biological effects of the drug and are caused by immunological and non-immunological mechanisms.

OBJECTIVES

To describe the immunological mechanisms of hypersensitivity reactions (HSR) to drugs, their epidemiology, risk factors, classification, clinical manifestations, diagnosis, treatment, and prognosis.

METHODS

A review of the most current literature in English and Spanish was carried out, in the main databases, related to the HSR of various drug groups.

RESULTS

This study describes the terms used to define ADRs and HSRs, their classification and clinical manifestations, current diagnostic tools, treatment algorithms and prognosis of the most frequently used medications and with the highest prevalence of reported adverse events.

CONCLUSION

ADRs are a challenging entity, with a complex pathophysiology that has not been fully understood. Its approach requires a careful consideration since not all drugs have validated tests for their diagnosis nor a specific treatment. When indicating the use of any drug, the severity of the disease, the availability of other treatments and the potential risks of developing future adverse events should always be taken into consideration.

Successful identification of culprit drugs of perioperative anaphylaxis by repeated skin testing after negative first skin tests in a patient with a long distant history of perioperative anaphylaxis

Background

Perioperative anaphylaxis is a severe immediate hypersensitivity reaction to drugs administered in immediate temporal association to surgical procedures. The European Academy of Allergy and Clinical Immunology recommends allergologic tests be performed within the golden period of between 1 and 4 months after the date of the event to avoid false negatives. Nonetheless, many obstacles prevent patients from receiving diagnostic tests within the recommended time frame.

Case presentation

A 39-year-old male with congenital glaucoma had a history of multiple episodes of perioperative anaphylaxis since the age of 1 year including generalized urticaria, bronchospasm, cyanosis, and hypotension. Because the sequence of events was unclear due to incomplete documentation of operations and the destruction of medical records, the allergists tested different perioperative drugs on the patient. Although the first test results were all negative, repeated tests at 6 weeks were positive for morphine and ketamine. We identified more than one causative drug at the second round of skin tests. Using recommended skin test concentrations, negative skin tests in 5 control subjects could support the validity of the second test. The patient underwent sinus surgery in the next 3 months after the second skin test using propofol, midazolam, sevoflurane, chlorhexidine, and cefazolin without any anaphylactic reactions.

Conclusions

Repeated skin tests after negative results of the first tests may identify the causative drugs, thus providing optimal patient safety, and should be considered under the physician's discretion together with consideration of the severity of the allergic symptoms, time interval from last reactions, and the patient's consent.

Perioperative Anaphylaxis: Evaluation and Management

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.