No cases of perioperative allergy to local anaesthetics in the Danish Anaesthesia Allergy Centre

Relationship between perioperative anaphylaxis and history of allergies or allergic diseases: A systematic review and meta-analysis with meta-regression

STUDY OBJECTIVE

We conducted this meta-analysis to summarize the available evidence and evaluate the relationship between a history of allergies/allergic diseases and perioperative anaphylaxis to offer preventive decision support.

DESIGN

Systematic review and meta-analysis of observational studies.

SETTING

We searched the MEDLINE (OVID), EMBASE, and the Cochrane Central Register of Controlled Trials databases for observational studies. Two investigators independently performed the search, screened the articles, and collected the study details.

MEASUREMENTS

Several databases were systematically searched to evaluate the relationship between a history of allergies/allergic diseases and perioperative anaphylaxis using subgroup analysis, sensitivity analysis and meta-regression.

MAIN RESULTS

A total of 19 studies involving 672 anaphylaxis episodes, 5608 immune-mediated reactions, and 1126 severe episodes met the eligibility criteria and were included in this meta-analysis. Drug allergies, food allergies, a history of allergies, and atopy increased the incidence of perioperative anaphylaxis (Drug allergies, odds ratio [OR] 3.54, 95% confidence interval [CI] 1.07-11.69; Food allergies, OR 2.29, 95% CI 1.23-4.26; A history of allergies, OR 4.86, 95% CI 3.65-6.49; Atopy, OR 3.58, 95% CI 1.47-8.71), but not the presence of immune-mediated reactions and the severity of perioperative anaphylaxis.

CONCLUSIONS

Patients with previous drug allergies, food allergies, a history of allergies, or atopy are more likely to develop anaphylaxis during the perioperative period. Additional studies should be carried out to determine whether a history of allergies/allergic diseases is a major factor for perioperative anaphylaxis when confounders are controlled.

Analysis of Allergy and Hypersensitivity Reactions to COVID-19 Vaccines According to the EudraVigilance Database

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic presented a new challenge in modern medicine: the development of vaccines was followed by massive population vaccinations. A few reports on post-vaccination allergic reactions have made patients and medical personnel uneasy as to COVID-19 vaccines' allergic potential. Most of the studies in this area to date have been small, and some that were based on global databases skipped most of the allergic diseases and concentrated only on anaphylaxis. We aimed to analyze the incidence of serious allergic reactions based on the EudraVigilance (EV) database, regardless of the reported symptoms and allergy mechanism.

METHODS

The total number of administrated vaccine doses was extracted on 5 October 2023 from Vaccine Tracker and included all administrations since vaccinations began in the European Economic Area (EEA). Data on serious allergic reactions to COVID-19 vaccines were extracted from the EudraVigilance database with the same time point. The code names of 147 allergic symptoms or diseases were used.

RESULTS

The frequency of serious allergic reactions per 100,000 administered vaccine doses was 1.53 for Comirnaty, 2.16 for Spikevax, 88.6 for Vaxzevria, 2.11 for Janssen, 7.9 for Novavax, 13.3 for VidPrevtyn Beta, and 3.1 for Valneva. The most prevalent reported reactions were edema (0.46) and anaphylaxis (0.40). Only 6% of these reactions were delayed hypersensitivity-oriented.

CONCLUSIONS

The overall frequency of potential serious allergic reactions to COVID-19 is very rare. Therefore, COVID-19 vaccines seem to be safe for human use. The lowest frequency of allergic reaction was observed for Comirnaty and the highest for Vaxzevria.

[Diagnostics of drug allergies and intolerances]

The prevalence of hypersensitivity reactions to drugs is increasing. Currently, this affects more than 7% of the world population. Nonsteroidal anti-inflammatory drugs (NSAID) and beta-lactam antibiotics (BLA) are by far the most common pharmaceutical preparations involved in hypersensitivity reactions to drugs. Misdiagnoses are frequent and BLA allergies present a danger that can lead to adverse health outcomes. Therefore, delabeling (exclusion of a suspected diagnosis) is paramount for those affected. Following the occurrence of uncomplicated maculopapular exanthemas, outpatient oral drug provocation can be safely considered in children without prior skin tests. Immediate perioperative reactions are rare. The approach to studying these complex reactions requires collaboration between allergologists and anesthesiologists to provide the best possible care for these patients.

Allergy to Local Anesthetics is a Rarity: Review of Diagnostics and Strategies for Clinical Management

Local anesthetics (LA) are commonly used in procedures and in topical agents for pain management. With the increasing use of LA drugs, the management of LA reactions is more frequently encountered in the office and in operating rooms. True allergic reactions involving IgE-mediated reactions and anaphylaxis are rare; they have only been identified in case reports and account for less than 1% of adverse LA reactions. Most reactions are non-allergic or are a result of hypersensitivity to other culprits such as preservatives, excipients, or other exposures. LA reactions that are misclassified as true allergies can lead to unnecessary avoidance of LA drugs or delays in surgical procedures that require their use. A detailed history of prior LA reactions is the first and most crucial step for understanding the nature of the reaction. Reactions that are suspicious for an immediate hypersensitivity reaction can be evaluated with skin prick and intradermal testing with subsequent graded challenge. Reactions that are suspicious for a delayed hypersensitivity reaction can be evaluated with patch testing.

Risk Factors for Immediate-Type Local Anesthetic Hypersensitivity Reactions in Pediatric Patients: A Retrospective Case-Control Study

Background

Local anesthetics (LA) are relatively safe and rarely cause immediate hypersensitivity reactions. The data on immediate LA hypersensitivity and its risk factors in children are limited.

Aim

To evaluate risk factors of immediate LA hypersensitivity.

Methods

The retrospective case-controlled study included 17 patients with confirmed immediate LA hypersensitivity. For each patient, three age- and gender-matched control subjects were included in the study. LA hypersensitivity was excluded by skin tests and subcutaneous drug provocation tests in all control subjects.

Results

The most common allergic assessment in the patient/control group was for lidocaine (n=5; 29.4%, vs n=23; 45.1%). Suspected LA hypersensitivity reactions were found to be associated with cutaneous manifestations in 14 (82.4%) patients and in 7 (13.7%) of the controls. A history of exposure to local anesthetics twice or more was present in 11 (64.7%) patients vs 6 (11.8%) controls. In conditional regression analysis, repeated LA exposure (≥2) and cutaneous findings were determined as significant risk factors (Odds Ratio [OR]:5.7; 95% Confidence Interval [CI]:1.2–27.1; P=0.029 and (OR:17.3; 95% CI:3.6–82.5; P<0.001, respectively).

Conclusion

Cutaneous manifestations and a history of LA exposure twice or more were predictive factors for LA allergy confirmed by skin test in children.

Identification of Risk Factors and Cross-Reactivity of Local Anesthetics Hypersensitivity: Analysis of 14-Years' Experience

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.

The effect of topical lidocaine on intradermal testing in atopic dogs

BACKGROUND

Intradermal testing (IDT) most often requires sedation. Topical lidocaine offers an adjunct or alternative to sedation.

HYPOTHESIS/OBJECTIVES

We hypothesized that topical lidocaine would significantly reduce reactions to intradermal injections and that atopic dogs treated with topical lidocaine would have similar results with IDT to atopic dogs tested without topical lidocaine.

ANIMALS

Fifteen client-owned atopic dogs.

METHODS

In Part I, a 5% lidocaine patch, 5% lidocaine cream and a control with no active ingredients were compared. The lowest pain score during intradermal injection was established in six atopic dogs. Fifteen atopic dogs were enrolled in Part II, and lidocaine cream (found to be most effective in Part 1) was applied randomly to a single side of the thorax. An IDT was performed on each side of the chest. Subjective and objective scores of the control and lidocaine treatment sides were compared 15 and 30 min post-injection.

RESULTS

The 5% lidocaine cream had the greatest reduction in pain score associated with intradermal injection. There were no significant differences in mean wheal diameter for any evaluated allergen at any time point between the control and lidocaine-treated sides. There was high agreement between the two groups when assessing the subjective score for all but one allergen.

CONCLUSIONS AND CLINICAL IMPORTANCE

Topical lidocaine may be used as adjunctive analgesia during IDT with caution in interpretation of subjective house dust scoring. Lidocaine cream appeared to reduce pain score and may allow reduction in concurrent sedation.

Risk of True Allergy to Local Anesthetics: 10-Year Experience from an Anesthesia Allergy Clinic in China

Background

Local anesthetics (LAs) have been widely used throughout the healthcare settings, especially in local anesthesia and pain management. The incidence of allergic reactions to LAs remains uncertain. The danger of allergic reactions to the use of LAs in every day of clinical practice is a matter of great concern. Therefore, it is necessary to investigate the risk of true allergy to LAs.

Methods

This study retrospectively evaluated the medical records of patients who were referred to an anesthesia allergy clinic in China and underwent allergy tests with LAs over a 10-year period from 2009 to 2019. The following information was collected from medical records: demographics of the patients, reasons for referral, clinical features of drug hypersensitivity reaction (DHR), and test results with LAs. Skin tests combined with an in vitro method, basophil activation test (BAT), were used to investigate allergic reactions to LAs.

Results

A group of 109 patients were included in the analysis. The main reason for referral was the presence of a suspected DHR after procedures with LAs (n=68, 62%), the second most common reason for referral was a history of DHR to other drugs and the need to use LAs for upcoming procedures (n=41, 38%). Of the 68 patients with a suspected DHR to LAs, only six cases presented true allergy and showed positive results in skin tests and/or BAT. And all 41 patients who had a history of DHR to other drugs presented negative in all tests.

Conclusion

Risk of true allergy to LAs may be very low. However, patients with a suspected history of DHR to LAs should be considered for allergy tests. Skin tests and BAT may be useful in the investigation and diagnosis of true allergy to LAs in clinical practice.

An EAACI position paper on the investigation of perioperative immediate hypersensitivity reactions

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.

Lidocaine as a Rare and Hidden Allergen in the Perioperative Setting: A Case Report

Local anesthetics are used throughout the health care system. In the perioperative setting and in other settings of exposure to local anesthetics, true allergy is reported very rarely. We present an unusual case of immediate-type perioperative hypersensitivity to lidocaine with cross-reaction to mepivacaine, which was missed on initial investigation. This case illustrates that lidocaine may be a "hidden allergen" in the perioperative setting and should always be considered a potential culprit in cases of suspected perioperative hypersensitivity. The case also demonstrates that suspected perioperative hypersensitivity requires highly specialized investigation and close collaboration between allergists and anesthesiologists.

Pediatric drug hypersensitivity: which diagnostic tests?

Along with the anamnesis and clinical evaluation, diagnostic tests are one of the mainstream key points in the evaluation and management of drug hypersensitivity reactions (DHR). A wide knowledge gap, both in diagnosis and management of pediatric DHR, must be filled.  Only a few published studies evaluated sensitivity and specificity of skin and in vitro tests in children. However, selected case series show that diagnostic work-up for adults could be useful, with some limitations, in pediatric age. Indeed, despite improvement in in vivo and in vitro diagnosis, drug provocation test remains the gold standard in pediatric age, too. Unmet needs in children include multi-centric studies on incidence of DHR, utility and feasibility of in vivo and in vitro diagnostic tests and specifically dedicated guidelines for the diagnosis and management of DHR in children.

[Dental care for patients at risk of adverse reaction to local anesthetics]

The study comprised 53 patients with side effect history to local anesthetics. The reasons for the occurrence of adverse reactions to local anesthetics was analyzed, and the frequency of their occurrence in dental practice was studied. It was found that in most patients (85%) with 'allergic reactions' to local anesthetics the diagnosis was unreasonable and incompetent. In most cases psychosomatic reactions were mistaken for an immediate allergic reaction. The prevalence of adverse reactions to local anesthetics was 1 case per 448 injections (1:448), true allergic reactions was documented in 0.1% cases.

Perioperative drug reactions - practical recommendations for allergy testing and patient management

Background

Allergy testing for perioperative drug reactions poses a particular diagnostic challenge. Neuromuscular blocking agents (NMBA) and antibiotics are among the most common triggers. In principle, however, any drug administered perioperatively is capable of causing a hypersensitivity reaction.

Methods

This article is an overview of selected scientific articles and is based on research in PubMed, specialist databases, and guidelines.

Results

Besides patient's history and laboratory tests (the latter being feasible to only a limited extent), skin tests play a particularly important role. To obtain clinical relevant results, profound knowledge on the best point in time for testing, the drug concentrations to be used, how to perform tests correctly, and the assessment criteria is of special importance.

Conclusion

Final outcomes of the diagnostic procedures should be providing thorough information of the patient about the findings, drugs that should be avoided in the future as well as alternative preparations, and, if necessary, preventive measures to be taken in the event of further surgical interventions.

Twenty Years' Experience with Anaphylaxis-Like Reactions to Local Anesthetics: Genuine Allergy is Rare

BACKGROUND

Anaphylaxis-like reactions occur within minutes after the application of local anesthetics (LA), most commonly during dental interventions. Impressive symptoms including respiratory distress or loss of consciousness frequently give rise to a suspicion of allergy and may prompt patients and treating physicians to refuse future LA injections.

OBJECTIVE

Nonallergic mechanisms are responsible for the majority of LA-induced immediate-type reactions. In view of the preponderance of nonallergic reactions, the question arises whether genuine LA allergy may be missed during routine testing procedures.

METHODS

We retrospectively evaluated clinical data and test results from patients referred to our allergy clinic within the past 20 years for diagnostic workup of LA-induced immediate-type reactions.

RESULTS

Of 402 evaluated patients, 29 had an episode of acute urticaria within 30 minutes after LA injections, and the remaining 373 had a history of mainly subjective cutaneous, respiratory, cardiovascular, and neurological complaints. Of the patients reporting urticaria with or without angioedema, 14 were diagnosed with a spontaneous episode of urticaria, 13 had allergic or nonallergic reactions to other agents, and 2 had IgE-mediated LA allergy. LA allergy was definitely excluded by 771 subcutaneous provocation tests with skin test negative LA, thereby demonstrating the high predictive value of negative intradermal testing.

CONCLUSIONS

Skin testing and provocative LA challenge are useful to exclude LA allergy, and this testing procedure seems to be appropriate to identify the extremely rare cases with IgE-mediated LA allergy.

International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis

BACKGROUND

Critical examination of the quality and validity of available allergic rhinitis (AR) literature is necessary to improve understanding and to appropriately translate this knowledge to clinical care of the AR patient. To evaluate the existing AR literature, international multidisciplinary experts with an interest in AR have produced the International Consensus statement on Allergy and Rhinology: Allergic Rhinitis (ICAR:AR).

METHODS

Using previously described methodology, specific topics were developed relating to AR. Each topic was assigned a literature review, evidence-based review (EBR), or evidence-based review with recommendations (EBRR) format as dictated by available evidence and purpose within the ICAR:AR document. Following iterative reviews of each topic, the ICAR:AR document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:AR document addresses over 100 individual topics related to AR, including diagnosis, pathophysiology, epidemiology, disease burden, risk factors for the development of AR, allergy testing modalities, treatment, and other conditions/comorbidities associated with AR.

CONCLUSION

This critical review of the AR literature has identified several strengths; providers can be confident that treatment decisions are supported by rigorous studies. However, there are also substantial gaps in the AR literature. These knowledge gaps should be viewed as opportunities for improvement, as often the things that we teach and the medicine that we practice are not based on the best quality evidence. This document aims to highlight the strengths and weaknesses of the AR literature to identify areas for future AR research and improved understanding.

Risk of Immediate-Type Allergy to Local Anesthetics Is Overestimated-Results from 5 Years of Provocation Testing in a Danish Allergy Clinic

BACKGROUND

Local anesthetics (LAs) are used in many health care settings and exposure during a lifetime is almost inevitable. Immediate-type allergy to LAs is considered rare among allergy experts but is commonly suspected by health care workers from other specialties, and by patients.

OBJECTIVE

The main aim of this study was to investigate the incidence of immediate-type allergy to LAs in our regional allergy clinic over the 5-year period 2010 to 2014.

METHODS

This was a retrospective single-center study of patients referred to a regional allergy clinic (excluding patients with perioperative reactions) with suspected immediate allergy to LAs, who had undergone subcutaneous provocation with 1 or more LAs. Patients were identified in the hospital clinical coding system and clinical information about the reaction and investigation results was obtained from their medical records.

RESULTS

A total of 164 patients (123 women/41 men; median age, 56 years; range, 7-89 years) who had 189 provocations with LAs were included over the 5-year period 2010 to 2014. All 164 patients had negative subcutaneous provocations to all 189 tests with LAs (95% CI, 0%-1.83%). Another allergen was identified in 10% (n = 17) of the patients.

CONCLUSIONS

None of the 164 patients with suspected immediate-type allergy to LAs reacted on provocation. Thus, no patients have been diagnosed with an immediate allergy to LAs in our regional allergy clinic in the 5-year period studied, and allergy to LAs must be considered very rare. Alternative mechanisms should be considered, but if symptoms are consistent with allergy, other potential allergens should be investigated.