Intraoperative anaphylaxis to neuromuscular blocking agents: the incidence over 9 years at two tertiary hospitals in South Korea

Rocuronium-Induced Anaphylaxis in the Perioperative Period: A Clinical Review

Rocuronium, a nondepolarizing neuromuscular blocking agent used for muscle relaxation especially during endotracheal intubation, can cause hypersensitivity reactions. This article provides an overview of anaphylactic reactions; risk factors; and the pathophysiology, presentation, diagnosis, treatment, and nursing implications associated with rocuronium-induced anaphylaxis. Life-threatening anaphylaxis can be immunoglobulin E-mediated or non-immunoglobulin E-mediated and usually occurs after the first dose. Anaphylaxis can present with hypotension and bronchospasm; cutaneal symptoms, such as erythema, may not be obvious. Diagnosis is initially presumptive and may require a transesophageal echocardiogram to rule out other causes of hypotension (eg, pulmonary embolus). Emergency treatment begins with epinephrine administration and fluid boluses; cardiac support devices may be needed. Definitive diagnosis requires early measurement of histamine and tryptase levels and skin testing after the patient recovers from the reaction. Perioperative nurses should be prepared to participate in emergency treatment of anaphylaxis and advocate for testing for a definitive diagnosis.

Neuromuscular blocking agent re-exposure in a retrospective cohort with neuromuscular blocking agent-associated anaphylaxis

BACKGROUND

Neuromuscular blocking agents (NMBAs) are one of the most common causes of perioperative anaphylaxis. Although skin test positivity may help identify reactive NMBAs, it is unclear whether skin test negativity can guarantee the safety of systemically administered NMBAs.

OBJECTIVE

This study aimed to evaluate the real-world safety of alternative NMBAs screened using skin tests in patients with suspected NMBA-induced anaphylaxis.

METHODS

A retrospective cohort of suspected NMBA-induced anaphylaxis were recruited among patients at Seoul National University Hospital from June 2009 to May 2021, and their characteristics and outcomes were assessed.

RESULTS

A total of 47 cases (0.017%) of suspected anaphylaxis occurred in 282,707 patients who received NMBAs. Cardiovascular manifestations were observed in 95.7%, whereas cutaneous findings were observed in 59.6%. Whereas 83% had a history of undergoing general anesthesia, 17% had no history of NMBA use. In skin tests, the overall positivity to any NMBA was 94.6% (81.1% to culprit NMBAs) and the cross-reactivity was 75.7%, which is related to the chemical structural similarity among NMBAs; the cross-reactivity and chemical structure similarity of rocuronium were 85.3% and 0.814, respectively, with vecuronium; this is in contrast to 50% and 0.015 with cisatracurium and 12.5% and 0.208 with succinylcholine. There were 15 patients who underwent subsequent surgery with a skin test-negative NMBA; whereas 80.0% (12/15) safely completed surgery, 20.0% (3/15) experienced hypotension.

CONCLUSION

Similarities in chemical structure may contribute to the cross-reactivity of NMBAs in skin tests. Despite the high negative predictability of skin tests for suspected NMBA-induced anaphylaxis, the potential risk of recurrent anaphylaxis has not been eliminated.

Perioperative Hypersensitivity Evaluation and Management: A Practical Approach

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.

Severe perioperative anaphylaxis: Incidence in a tertiary hospital in Spain over a 20-year period. A historical cohort study

OBJECTIVE

To assess the incidence of severe perioperative anaphylaxis, the mechanisms involved, the value of laboratory/skin tests, and the most effective treatments.

METHODS

A historical cohort study conducted in a tertiary public hospital in Spain. Patients that had undergone anaesthesia during the 20-year period were included. In these patients, 66 cases of severe anaphylaxis were found. In patients with suspicion of severe anaphylaxis, levels of blood histamine at less than 15min and serum tryptase at 2, 6, and 24h following the reaction were determined. Skin and specific IgE tests were performed between 4 and 8 weeks later.

RESULTS

Over the 20-year period, 288 594 anaesthetic procedures were performed. We observed cases of 66 severe anaphylaxis reaction (59% men; age, 60.8±17.3 years. Symptoms observed were cardiovascular (86%), respiratory (73%), and mucocutaneous (56%). Elevated serum tryptase levels were associated with degree of severity at 2 (P<.0001) and 6h (P=.026) and were highest in IgE-mediated reactions (P=.020). All patients required treatment, and 3 events were fatal. In 84.8% of patients, skin and/or specific IgE tests were positive for antibiotics (35.8%), non-steroidal anti-inflammatory drugs (23.1%), neuromuscular blocking agents (15.4%) and latex (15.4%).

CONCLUSIONS

The incidence of severe anaphylaxis in our hospital was 1 in 4.373 anaesthetic procedures, with a death rate of 4.5%. All cases required treatment. Serum tryptase was a good predictor of reaction severity. The most frequent causative agents were antibiotics, non-steroidal anti-inflammatory drugs, neuromuscular blocking agents and latex.

Could Artificial Intelligence Prevent Intraoperative Anaphylaxis? Reference Review and Proof of Concept

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.

Risk predictive tools of perioperative drug hypersensitivity reaction: A case-control study

Objective

We aimed to determine the risk factors of perioperative drug hypersensitivity reaction (DHR) and develop a predictive score for use in clinical practice.

Methods

A case-control study was conducted in patients who underwent anesthesia at a tertiary hospital in Thailand, between 2015–2018. DHR cases were graded clinically from 1 to 4 according to the World Federation of Societies of Anesthesiologists by two anesthesiologists. Controls were randomly matched with cases (ratio 2:1) by age group and month and type of surgery. Patient and anesthesia-related factors and agents given intraoperatively were recorded. A risk score was derived from the coefficients of the significant predictors of the final multivariate logistic regression model. Risk scores, adjusted odds ratios (OR) for perioperative DHR and 95% confidence intervals (CI) were determined.

Results

Overall, 325 cases and 650 controls were recruited. The severity of DHR was grade 1 (72.9%), grade 2 (24%), and grade 3 (3.1%). Our risk predictive tools for perioperative DHR provided a sensitivity of 62% and specificity of 65%. Predictive scores of subgroups of moderate to severe DHR showed high specificity (80%) but low sensitivity (47%). Common predictors of overall DHR and moderate to severe DHR were history of drug allergy to 2 or more drug categories (score 2.5–3.5), being allergic to analgesics (score 2.5–4.0), and intraoperative morphine use (score of 1). The sole predictor of high-risk perioperative DHR (score ≥3.5) was airway management with an endotracheal tube intubation (OR 5.6, 95% CI 2.2–14.4) whereas history of allergic rhinitis (OR 11.7, 95% CI 1.3–105.1) was a predictor of high-risk moderate to severe DHR (score ≥2.5).

Conclusions

Our predictive tool for perioperative DHR provided a modest predictive ability. History of drug allergies, rhinitis, morphine use and endotracheal intubation were significant risk factors of DHR after adjusting for age and type of surgery.

Estimated Incidence of Sugammadex-Induced Anaphylaxis Using the Korea Adverse Event Reporting System Database

We aimed to investigate the incidence of sugammadex-induced anaphylaxis in a large Korean population. We retrospectively investigated the incidence of sugammadex-induced anaphylaxis between 2013 and 2019 from the database of the Korea Institute of Drug Safety-Risk Management-Korea Adverse Event Reporting System (KIDS-KAERS). We estimated the incidence of sugammadex-induced anaphylaxis from the KIDS-KAERS database, assuming that the reporting efficiency was 10%, 50%, and 100%, respectively. We also investigated its annual sales volume in Korea and assumed that the exposure to sugammadex was 95% of the estimated sales volume. During the study period, 1,401,630 sugammadex vials were sold, and 19 cases of sugammadex-induced anaphylaxis were identified in the KIDS-KAERS database. The estimated incidence of sugammadex-induced anaphylaxis was 0.0143%, 0.00279%, and 0.0014%, assuming a reporting efficiency of 10%, 50%, and 100%, respectively. All patients, except for one with a missing record, fully recovered after anaphylaxis. The incidence of sugammadex-induced anaphylaxis identified in the national pharmacovigilance database was lower than previously reported rates in other countries. Therefore, its use in general anesthesia should not be hindered by concerns about the resulting risk of anaphylaxis in Korea.

Comparative epidemiology of suspected perioperative hypersensitivity reactions

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.