Anaphylaxis during general anaesthesia: experience from a drug allergy centre in the UK

Clinical variables and genetic variants associated with perioperative anaphylaxis in Chinese Han population: A pilot study

Background

Perioperative anaphylaxis (POA) can lead to severe consequences. Identifying clinical risk factors and genetic loci associated with POA through pre-prescription screening may help reduce its incidence.

Methods

Using univariate regression and covariate-adjusted multivariate regression, we retrospectively analyzed the association between clinical characteristics and POA in 72 POA patients and 72 non-POA individuals. The discovery study of whole-exome association relied on whole-exome sequencing of 73 POA cases and 1339 healthy individuals. A replication study involving an independent set of 16 POA cases and 1339 healthy individuals confirmed this association. The accurate typing of human leucocyte antigen through exome sequencing (ATHLATES) algorithm and the whole-exome sequencing data were used for genotyping the human leucocyte antigen G (HLA-G) of 73 POA patients. The HLA-G of 16 POA cases and 122 non-POA patients were genotyped through Sanger sequencing. We used Fisher's exact probability method to compare the allele and carrier frequencies between POA patients and healthy individuals or non-POA patients. A Pc (P/Bonferroni correction coefficient) < 0.05 represents statistical significance.

Results

Regression analysis identified female sex, an unconfirmed food allergy label, and a history of prior surgery as clinical variables associated with POA. The whole-exome association discovery study identified a strong signal in the major histocompatibility complex region on chromosome 6, with the rs1130356 being the most significant locus (P = 1.5E-10, OR = 3.4, 95% CI = 2.4-4.9). The replication study verified the association between the rs1130356-T allele and POA cases (P = 1.0E-6, OR = 6.3, 95% CI = 3.1-12.7). Compared with non-POA patients, HLA-G∗01:01 (Pc = 2.4E-4, OR = 2.4, 95% CI = 1.6-3.6) was significantly enriched, while HLA-G∗01:04 (Pc = 1.2E-6, OR = 0.3, 95% CI = 0.2-0.5) was lessened in POA patients.

Conclusion

Our study suggested an association between POA and the risk factors of female sex, an unconfirmed food allergy label, and prior surgery. HLA-G, located in the human leucocyte antigen (HLA) region, may act as a surrogate genetic marker for POA. This suggests a causal relationship between this specific genomic region and POA. Our findings shed light on the contribution of human exome genetic variants to the susceptibility to POA.

Combined acupuncture-medicine anesthesia used in thyroid surgery: A systematic review and meta-analysis

BACKGROUND

Combined acupuncture-medicine anesthesia (CAMA) is extensively used in thyroid surgery in China. We conducted a systematic review and meta-analysis to assess the efficacy and safety of CAMA.

METHODS

We searched the China National Knowledge Infrastructure (CNKI), VIP database, WanFang database, PubMed, EMBASE, and the Cochrane Library for relevant literature. The term of literature was published before April 18, 2020, and there were no restrictions on publication language, region, or publication year. The inclusion criteria included a randomized controlled trial (RCT) of acupuncture combined with cervical plexus anesthesia. We used RevMan5.3 software for data analysis. If the chi-square test showed no significant heterogeneity (P > .10, I2 < 50%), we used the fixed-effect model to calculate risk ratio (RR) and mean difference. Otherwise, the random-effects model was used.

RESULTS

Overall, 18 RCTs involving 1211 patients were included in the study. The anesthesia significant rate (ASR) in the transcutaneous electrical acupoint stimulation (TEAS) plus cervical plexus block anesthesia (CPBA) and electroacupuncture (EA) plus CPBA groups was significantly higher compared with the CPBA group (TEAS + CPBA: P < .001; EA + CPBA: P < .001). The pooled effect values of the intraoperative heart rate (HR) and mean arterial pressure (MAP) were significantly lower in both the TEAS + CPBA and EA + CPBA groups relative to the control group (HR: P = .05, P < .001; the MAP: P = .002, P < .001; respectively). Moreover, the postoperative adverse reaction was markedly lower in the experimental group than in the control group (RR = 0.30, P < .001), and there was no heterogeneity between the two groups (P = .71, I2 = 0%).

CONCLUSION

Combined acupuncture-medicine anesthesia significantly increases the anesthesia significance rate, reduces the intraoperative heart rate, and blood pressure, and reduces the incidence of postoperative adverse reactions. However, more high-quality future studies should be conducted to validate the efficacy and safety of acupuncture combined anesthesia further.

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.

What do we know about perioperative hypersensitivity reactions and what can we do to improve perioperative safety?

Hypersensitivity reactions are an important aspect of perioperative care and are a crucial interdisciplinary issue in anaesthesiological practice, as well as allergological and laboratory diagnostics. This phenomenon was observed as early as the 1980s and 1990s in Western European countries, and knowledge on this subject has grown significantly over time. Although hypersensitivity reactions are not frequent events (the incidence of perioperative hypersensitivity reactions ranges from 1:386 to 1:13 000 procedures, with higher frequency - 1 per 6500 general anaesthesias with neuromuscular blocking agents administrations), their courses are unfortunately serious and life-threatening. It should also be noted that there is no information regarding the occurrence of perioperative hypersensitivity reactions in many countries. Hence, global assessment of the problem is underestimated. The primary source of actual knowledge comes from epidemiological studies, which indicate an increasing frequency of hypersensitivity reaction occurrence and changes in aetiological factors. The first report from France (1984 to 1989) described two main causes - neuromuscular blocking agents and hypnotic agents. The following years confirmed an increase in perioperative hypersensitivity reactions associated with latex and antibiotics. The most recent data from the National Audit Project 6 indicated increased participation of antibiotics, chlorhexidine, and contrast agents. The results of epidemiological analyses are the basis of medical management guidelines and practice modification. Thanks to the activity of many organisations monitoring the intensity and nature of perioperative hypersensitivity reactions, guidelines for diagnostics and management have been developed. This article presents the results of numerous studies, including the first and the most recent, from various geographical regions. The clinical significance, pathogenesis mechanisms are also discussed. This publication also presents important directions for further scientific and epidemiological research on perioperative hypersensitivity reactions.Key messagesThe incidence of perioperative hypersensitivity reactions ranges from 1:386 to 1:13 000 procedures, with higher frequency - 1 per 6500 general anaesthesias with neuromuscular blocking agents administrations.Reactions may occur during the first episode of anaesthesia, most frequently in the induction of general anaesthesia, and much less frequently during postoperative follow-up.The first reports of perioperative hypersensitivity reaction come from the 1990s, and knowledge on this subject has grown significantly over time.In many countries, multidisciplinary teams and organisations have been established to identify, monitor the occurrence of this phenomenon, and have set the directions of medical activities and have changed the rules and recommendations.There is no information about the occurrence of perioperative hypersensitivity reactions in many countries, and global assessment of the problem is underestimated. Additionally, there is a great need to develop a system to monitor their occurrence in other countries.The long-term epidemiologic studies have demonstrated variability in pharmacologic triggers. However, the main pharmacological substances (antibiotics, muscle relaxants, disinfectans, contrast agents) are related to aspects of patient safety during anaesthesia.

The nature and reported incidence of suspected perioperative allergic reactions: A cross-sectional survey

STUDY OBJECTIVE

Perioperative allergic reactions (POHs) are common and can lead to severe intraoperative instability and even mortality. In contrast to the situation in developed countries, where databases of perioperative anaphylaxis are well documented and analyzed, relevant data are lacking in China. Therefore, we aimed to conduct a national survey to explore the characteristics of perioperative allergic reactions, as well as the knowledge and attitudes toward management and reporting among anesthesiologists.

DESIGN

Cross-sectional survey.

SETTING

Anesthesia department.

PATIENTS

A nationally representative sample comprising anesthesiologists from 12 province-level regions was selected.

MEASUREMENTS

A 20-item questionnaire was designed and validated using the Delphi method. Survey distribution was performed between June 2019 and January 2020 by the Chinese Society of Anesthesiology (CSA), which is the official academic society of Chinese anesthesiologists. Responses were compiled and analyzed.

MAIN RESULTS

We received responses from 4389 anesthesiologists across China. The estimated rate of suspected POH was 2/1000 patients (0.2%). On average, an anesthesiologist encountered 2.1 suspected POH cases per year. Neuromuscular blocking agents (NMBAs) were perceived as the most common causative agents, followed by antibiotics and succinylated gelatin. The rates of referral and allergy consultations were very low. Institutional support, including protocol development, cognitive aids, and tool kits, was not ideal. Additionally, the management of POH varied substantially. Most anesthesiologists believed that reporting and documenting POH was necessary.

CONCLUSIONS

Our survey revealed that POH is commonly encountered by Chinese anesthesiologists, but few patients are referred to allergy specialists or clinics for further investigation. A standardized recommendation based on research and data derived from Chinese patients is required.

Effect of body mass index and rocuronium on serum tryptase concentration during volatile general anesthesia: an observational study

OBJECTIVE

Female sex, body mass index (BMI), and neuromuscular blocking agents are risk factors of perioperative hypersensitivity reactions. This study aimed to investigate the effect of rocuronium on serum tryptase concentrations during general anesthesia in overweight and obese women.

METHODS

The study was conducted in two groups: Group I (n=66) underwent volatile anesthesia with rocuronium and group II (n=60) underwent volatile anesthesia without any muscle relaxant. Serum tryptase concentration (STC) measurements were performed at baseline (STC 0) and postoperatively (STC 1). ClinicalTrials.gov: NCT04035707 RESULTS: The highest median value of STC 0 was seen in obese patients (3.44 μg L-1) and it was significantly higher than in overweight (p=0.01) and underweight patients (p=0.03). The maximum STC 0 was observed in overweight patients (20.4 μg L-1). In group I, STC 0 in obese patients presented the highest median value (4.49 μg L-1), and was significantly higher than in overweight patients (p=0.03), and had significantly higher STC 1 than patients with normal BMI (p=0.04). STC 0 and STC 1 in overweight and obese female patients did not differ significantly between groups. STC 1 did not correlate with rocuronium doses. In group I, BMI positively correlated with the duration of rocuronium infusion (rho=0.37) and STC 1 positively correlated with BMI (rho=0.32).

CONCLUSION

Excess weight and obesity predispose to higher preoperative serum tryptase values. Postoperative STC is not linked to rocuronium doses. BMI is the main determinant factor of STC during combined volatile general anesthesia.

Recent developments and highlights in drug hypersensitivity

Drug hypersensitivity reactions (DHRs) are nowadays the third cause of allergy after rhinitis and asthma with a significant increase in prevalence in both adults and paediatric population with new drugs included as culprit. For this, DHRs represent not only a health problem but also a significant financial burden for affected individuals and health systems. Mislabelling DHRs is showing to be a relevant problem for both, false label of drug allergic and false label of nonallergic. All this reinforces the need to improve accurate diagnostic approaches that allow an appropriate management. Moreover, there is a need for training both, nonallergist stakeholders and patients to improve the reaction identification and therefore decrease the mislabelling. The use of allergy cards has shown to be relevant to avoid the induction of DHRs due to the prescription of wrong medication. Recent developments over the last 2 years and highlights about risk factors, diagnostic approaches, mechanisms involved as well as prevention actions, and management have been reviewed. In these papers, it has been outlined the need for correct diagnosis and de-labelling of patients previously false-reported as allergic, which will improve the management and treatment of patients with DHRs.

Allergy alerts - The incidence of parentally reported allergies in children presenting for general anesthesia

BACKGROUND AND AIM

Pediatric patients increasingly report allergies, including allergies to food and medications. We sought to determine the incidence and, nature of parent-reported allergies in children presenting for surgery and its significance for anesthetists.

METHODS

We prospectively collected data on admissions through our surgical admission unit over a 2-month period at a pediatric tertiary care teaching hospital. Data collected included patient demographics, history of atopy, with more comprehensive information collected if an allergy was reported. A clinical immunologist and an anesthetist reviewed the documentation of all patients reporting an allergy.

RESULTS

We reviewed 1001 pediatric patients, 158 (15.8%) patients with parent-reported allergies; to medications/drugs (n = 73), food (n = 66), environmental allergens (dust/grasses, n = 35), tapes/dressings (n = 27), latex (n = 4), and venom (eg, bee, wasp, n = 9). Forty-one patients reported antibiotic allergies, with Beta-lactam antibiotics being the most common, with the majority presenting with rash alone (57%). Ten patients reported allergies to nonsteroidal anti-inflammatory drugs and eight to opioids. Twenty-four patients reported egg and/or peanut allergy. Only 3/1001 (0.3%) patients were deemed to have evidence of likely IgE-mediated drug allergy. Of the reported allergies, only 60 (38.2%) had been investigated prior, most likely to be followed up were food (53%) and environmental allergies (44.4%). Only 4/73 (5.5%) reported medication allergies had further follow-up. Just four patients (0.4% of the entire cohort) had drug sensitivities/allergies that were likely to majorly alter anesthesia practice.

CONCLUSION

Only the minority of parent-reported allergies in pediatric surgical patients were specialist confirmed and likely to be clinically relevant. Self-reported food allergy is commonly specialist verified whereas reactions to medications were generally not. Over-reporting of allergies is increasingly common and limits clinician choice of medications. Better education of patients and their families and more timely verification or dismissal of parent-reported reactions is urgently needed.

Prevention of rocuronium induced mast cell activation with prophylactic oleuropein rich diet in anesthetized rabbits1

PURPOSE

The effect of a prophylactic oleuropein-rich diet before anesthesia accompanied by the widely-used steroid-based neuromuscular drug rocuronium on mast cell activation was investigated in the study.

METHODS

14 rabbits used in the study. The rabbits in the oleuropein group were given oleuropein-rich extract added to the animals' water at doses of 20 mg/kg oleuropein for 15 days orally. After 15 days, all rabbits in the two groups were given general anesthesia with rocuronium of 1 mg/kg. After 1 day, animals were sacrificed and the liver tissue sections stained with H&E, toluidine blue and tryptase for immunohistochemical study.

RESULTS

There was no statistically significant difference between ALT, AST and albumin averages of the oleuropein and control groups (p> 0.05). The tryptase average of the control group was higher than the tryptase average of the oleuropein group and this difference was statistically significant (p=0.003). The T. blue average in the oleuropein group was higher than the control group. However, there was no statistically significant difference between groups (p=0.482).

CONCLUSIONS

Rocuronium adverse effects, like hypersensitivity and anaphylaxis, may limit routine use of this substance. The use of oleuropein reduced the number of inflammatory cells and prevented degranulation.

Are Perioperative Antibiotics Necessary During Direct Microlaryngoscopy?

OBJECTIVES/HYPOTHESIS

There are currently no established recommendations for the use of perioperative antibiotics (PAs) to prevent surgical site infections (SSIs) for direct microlaryngoscopy (DML). This study examined the incidence of SSI in patients undergoing DML with and without PAs.

STUDY DESIGN

Retrospective, multi-institutional chart review.

METHODS

A retrospective, multi-institutional chart review was performed at four tertiary referral academic medical centers. Patients undergoing DML from 2010 to 2017 were identified using Current Procedural Terminology codes. Medical records of patients undergoing DML with biopsy, microsurgery, laser ablation, or vocal fold injection who had adequate follow-up were reviewed. Procedures with significant cartilage destruction, concurrent open surgery, or esophageal surgery were excluded. Data recorded included age, gender, pacemaker history, American Society of Anesthesiologists class, wound class, indication for surgery, use of laser, complications, emergency room visits, hospitalizations, pain, fever, and postoperative steroid and antibiotic prescriptions. Presence or absence of SSIs was evaluated by a fellowship-trained laryngologist.

RESULTS

There were 834 patients who met inclusion criteria. Of those, 698 did not receive PAs and 136 received PAs. The median age of patients was 54 years of age in the PA group and 57.5 years of age in the non-PA group, and all cases were recorded as wound class II. Overall, 58% of surgeries involved use of carbon dioxide or potassium-titanyl-phosphate laser. Only one SSI was reported on follow-up in a patient who did receive PAs.

CONCLUSIONS

SSIs are exceedingly rare following DML. PA use is not indicated for routine DML.

LEVEL OF EVIDENCE

4 Laryngoscope, 128:2838-2843, 2018.

Neuromuscular blockers and reversal agents and their impact on anesthesia practice

Neuromuscular blockers have long been an intricate part of the anesthesia regimen. The scientific progress in pharmacology and physiology has strengthened their clinical relevance, has helped to delineate with precision their medical role, and has enhanced the safety and effectiveness of their use. New frontiers in research will define further the role of these agents in modern anesthesia practice and guide their expanding and discrete clinical applications.

Two Consecutive Preoperative Cardiac Arrests Involving Vancomycin in a Patient Presenting for Hip Disarticulation: A Case Report

While an abundance of literature exists describing adverse reactions to vancomycin (eg, nausea, vomiting, red man syndrome, acute kidney injury), there is scarce evidence demonstrating vancomycin anaphylactic reactions requiring cardiopulmonary resuscitation. We report a case of a patient who had 2 separate preoperative episodes of cardiac arrest following vancomycin that occurred 4 weeks apart. Both episodes of anaphylaxis required cardiopulmonary resuscitation, which led to a successful patient outcome. We discuss identification and treatment of vancomycin-induced anaphylaxis.

Anaphylaxis triggers in a large tertiary care hospital in Qatar: a retrospective study

BACKGROUND

Anaphylaxis is a serious allergic disease that may lead to death if not immediately recognized and treated. Triggers of anaphylaxis including food, drugs, and insect stings can vary widely. The incidence of anaphylaxis seems to be affected by age, sex, atopy, and geographic location. This study aims to examine the common triggers of anaphylaxis in Qatar.

METHODS

A total of 1068 electronic medical records were audited using power chart system: 446 from the medical coding system of anaphylaxis and 622 from the epinephrine auto-injectors (EAIs) dispensed during January 2012-December 2017.

RESULTS

Of 1068 patients, 574 (53.5%) had anaphylaxis; male to female ratio was 1.2, and 300 patients (77.9%) were less than 10 years old. The common triggers were food (n = 316, 55.0%), insect stings (n = 161, 28.0%), and drugs (n = 103, 17.9%). Common anaphylaxis food triggers were nuts (n = 173, 30.1%), eggs (n = 89, 15.5%), and seafood (n = 72, 12.5%), and common anaphylaxis medication triggers were antibiotics (n = 49, 8.5%) and nonsteroidal anti-inflammatory drugs (n = 30, 5.2%). Interestingly, 135 anaphylactic patients (23.5%) were due to black ant stings. The anaphylaxis triggers varied significantly between children and adults. Among children (less than 10 years), three quarters of the events were triggered by food (223, 74.3%) while among adults (20-55 years), insect stings (n = 59, 43.0%) and drugs (n = 44, 32.0%) were dominant.

DISCUSSION

This is the first national study stratifying anaphylaxis triggers among different age groups in Qatar. This study will serve as a guide for clinical practice in allergy clinics in Qatar and will help to assess future trends of anaphylaxis in Qatar.

Epidemiology, Mechanisms, and Diagnosis of Drug-Induced Anaphylaxis

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.