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Ebo DG, Sabato V, Mertens C, Van Gasse AL. Morphine-specific IgE testing in the assessment of neuromuscular blocking agent allergy. Comment on Br J Anaesth 2024; 132: 193-5. Br J Anaesth 2024; 132:976-977. [PMID: 38402108 DOI: 10.1016/j.bja.2024.01.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 01/05/2024] [Accepted: 01/25/2024] [Indexed: 02/26/2024] Open
Affiliation(s)
- Didier G Ebo
- Department of Immunology, Allergology, Rheumatology, The Infla-Med Centre of Excellence, Faculty of Medicine and Health Sciences, University of Antwerp and Antwerp University Hospital, Antwerpen, Belgium.
| | - Vito Sabato
- Department of Immunology, Allergology, Rheumatology, The Infla-Med Centre of Excellence, Faculty of Medicine and Health Sciences, University of Antwerp and Antwerp University Hospital, Antwerpen, Belgium
| | - Christel Mertens
- Department of Immunology, Allergology, Rheumatology, The Infla-Med Centre of Excellence, Faculty of Medicine and Health Sciences, University of Antwerp and Antwerp University Hospital, Antwerpen, Belgium
| | - Athina L Van Gasse
- Department of Immunology, Allergology, Rheumatology, The Infla-Med Centre of Excellence, Faculty of Medicine and Health Sciences, University of Antwerp and Antwerp University Hospital, Antwerpen, Belgium; Department of Paediatrics, The Infla-Med Centre of Excellence, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerpen, Belgium
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2
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Abdelshafi NA, Darwish HW, Alanazi AS, Naguib IA, Elkhouly HH, Khodary NS, Mohamed EH. Voltammetric analysis of pholcodine on graphene-modified GNPs/PTs with green assessment. BMC Chem 2024; 18:48. [PMID: 38449002 PMCID: PMC10919016 DOI: 10.1186/s13065-024-01146-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 02/19/2024] [Indexed: 03/08/2024] Open
Abstract
Pholcodine, an anti-tussive medication widely used as an over-the-counter, OTC drug, has recently faced restrictions in several countries. This paper presents a sensitive electrochemical approach for pholcodine detection. The electrochemical method involved fabricating a graphene nanoplatelets electrode, incorporating polythiophene nanospheres polymer to promote electron transfer and increase the activated surface area. Characterization of the fabricated electrode was performed using transmission electron microscopy, ATR-Fourier-transform infrared spectroscopy, X-ray crystallography, X-ray photoelectron spectroscopy, and electrochemical impedance spectroscopy. The electrochemical behavior of pholcodine with the fabricated electrode was investigated using cyclic voltammetry, chronoamperometry, square wave voltammetry (SWV), and differential pulse voltammetry (DPV). The developed electrode led to a linear response for pholcodine ranging from 10 to 45 mg/L with detection limits of 1.41 and 1.51 mg/mL for SWV and DPV, respectively and quantification limits of 4.27 and 4.57 mg/L for SWV and DPV, respectively. The proposed method has accurately recovered pholcodine in spiked serum samples with a recovery percentage ranging from 1.2 to 2.9%. The optimized method is found to be accurate, precise, and robust by applying validation parameters provided by International Council for Harmonization. Two green metrics were computed to assess the method's greenness, the findings showed that the developed method is environmentally friendly with minimum sample preparation steps.
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Affiliation(s)
- Nahla A Abdelshafi
- Department of Pharmaceutical Analytical Chemistry, School of Pharmacy, Badr University in Cairo, Badr City, Cairo, 11829, Egypt.
| | - Hany W Darwish
- Department of Pharmaceutical Chemistry, College of Pharmacy, King Saud University, 11451, Riyadh, Saudi Arabia
| | - Ashwag S Alanazi
- Department of Pharmaceutical Sciences, College of Pharmacy, Princess Nourah Bint Abdulrahman University, 11671, Riyadh, Saudi Arabia
| | - Ibrahim A Naguib
- Department of Pharmaceutical Chemistry, College of Pharmacy, Taif University, P.O. Box 11099, 21944, Taif, Saudi Arabia
| | - Hadeer H Elkhouly
- School of Pharmacy, Badr University in Cairo, Badr City, Cairo, 11829, Egypt
| | - Nehal S Khodary
- School of Pharmacy, Badr University in Cairo, Badr City, Cairo, 11829, Egypt
| | - Ekram H Mohamed
- Pharmaceutical Chemistry Department, Faculty of Pharmacy, The British University in Egypt, El Sherouk City, Cairo, 11837, Egypt
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Savic L, Hopkins PM. Pholcodine and allergy to neuromuscular blocking agents: where are we and how did we get here? Br J Anaesth 2024; 132:457-460. [PMID: 38071149 DOI: 10.1016/j.bja.2023.11.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 10/20/2023] [Accepted: 11/19/2023] [Indexed: 02/15/2024] Open
Abstract
Despite the purported link between pholcodine and neuromuscular blocking agent allergy, screening for prior pholcodine use offers no practical benefit to patients, and anaesthetists should continue to use a neuromuscular blocking agent where this is clinically indicated.
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Affiliation(s)
- Louise Savic
- Department of Anaesthesia, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
| | - Philip M Hopkins
- Department of Anaesthesia, Leeds Teaching Hospitals NHS Trust, Leeds, UK; Institute of Medical Research at St James's, University of Leeds, Leeds, UK
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Florvaag E, Johansson G. Pholcodine, perioperative anaphylaxis, and the European Medicines Agency: finally the decision to remove pholcodine from the market in the European Union. Br J Anaesth 2023:S0007-0912(23)00166-6. [PMID: 37149476 DOI: 10.1016/j.bja.2023.03.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 03/20/2023] [Accepted: 03/29/2023] [Indexed: 05/08/2023] Open
Abstract
Two recent case-control studies, both published in the British Journal of Anaesthesia, have shown that intake of pholcodine-containing cough medicines during the year preceding general anaesthesia significantly increased the risk of anaphylaxis caused by neuromuscular blocking agents. Both a French multicentre study and a single-centre study from Western Australia offer strong support to the pholcodine hypothesis for IgE-sensitisation to neuromuscular blocking agents. The European Medicines Agency, criticised for not taking preventive action at its first assessment of pholcodine in 2011, finally recommended a stop to sales of all pholcodine-containing medicines throughout the EU on December 1, 2022. Time will tell whether this reduces the incidence of perioperative anaphylaxis in the EU, as in Scandinavia.
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Mertes PM, Petitpain N, Tacquard C, Delpuech M, Baumann C, Malinovsky JM, Longrois D, Gouel-Cheron A, Le Quang D, Demoly P, Guéant JL, Gillet P. Pholcodine exposure increases the risk of perioperative anaphylaxis to neuromuscular blocking agents: the ALPHO case-control study. Br J Anaesth 2023; 131:S0007-0912(23)00104-6. [PMID: 36967281 DOI: 10.1016/j.bja.2023.02.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 02/15/2023] [Accepted: 02/16/2023] [Indexed: 06/18/2023] Open
Abstract
BACKGROUND Neuromuscular blocking agents (NMBAs) are among the leading cause of perioperative anaphylaxis, and most of these reactions are IgE mediated. Allergic sensitisation induced by environmental exposure to other quaternary ammonium-containing compounds, such as pholcodine, has been suggested. The aim of this study was to assess the relationship between pholcodine exposure and NMBA-related anaphylaxis. METHODS ALPHO was a multicentre case-control study, comparing pholcodine exposure within a year before anaesthesia between patients with NMBA-related perioperative anaphylaxis (cases) and control patients with uneventful anaesthesia in France. Each case was matched to two controls by age, sex, type of NMBA, geographic area, and season. Pholcodine exposure was assessed by a self-administered questionnaire and pharmaceutical history retrieved from pharmacy records. The diagnostic values of anti-pholcodine and anti-quaternary ammonium specific IgE (sIgE) were also evaluated. RESULTS Overall, 167 cases were matched with 334 controls. NMBA-related anaphylaxis was significantly associated with pholcodine consumption (odds ratio 4.2; 95% confidence interval 2.3-7.0) and occupational exposure to quaternary ammonium compounds (odds ratio 6.1; 95% confidence interval 2.7-13.6), suggesting that apart from pholcodine, other environmental factors can also lead to sensitisation to NMBAs. Pholcodine and quaternary ammonium sIgEs had a high negative predictive value (99.9%) but a very low positive predictive value (<3%) for identifying NMBA-related reactions. CONCLUSIONS Patients exposed to pholcodine 12 months before NMBA exposure have a significantly higher risk of an NMBA-related anaphylaxis. The low positive predictive values of pholcodine and quaternary ammonium sIgEs precludes their use to identify a population with a high risk of NMBA-related anaphylaxis. CLINICAL TRIAL REGISTRATION NCT02250729.
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Affiliation(s)
- Paul Michel Mertes
- Department of Anesthesia and Intensive Care, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, INSERM U1255, FMTS de Strasbourg, Strasbourg, France.
| | - Nadine Petitpain
- Nancy Regional University Hospital Center, Regional Pharmacovigilance Center of Nancy, Vandoeuvre-lès-Nancy, France
| | - Charles Tacquard
- Department of Anesthesia and Intensive Care, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, INSERM U1255, FMTS de Strasbourg, Strasbourg, France
| | - Marion Delpuech
- Department of MPI Unit of Methodology, Data Management and Statistic (UMDS), Nancy Regional University Hospital Center, Vandoeuvre-lès-Nancy, France
| | - Cédric Baumann
- Department of MPI Unit of Methodology, Data Management and Statistic (UMDS), Nancy Regional University Hospital Center, Vandoeuvre-lès-Nancy, France
| | - Jean Marc Malinovsky
- Anesthesia and Intensive Care Department, CHU de Reims, 51092 Reims Cedex and EA 3801 HERVI, Reims Champagne-Ardenne University, Reims, France
| | - Dan Longrois
- Hôpital Bichat-Claude Bernard, Anesthesiology and Critical Care Medicine Department, APHP, DMU PARABOL, Université Paris Cité, Bichat Hospital, Paris, France
| | - Aurélie Gouel-Cheron
- Anesthesiology and Critical Care Medicine Department, DMU PARABOL, Université Paris Cité, Bichat Hospital, AP-HP, Paris, France; Antibody in Therapy and Pathology, Pasteur Institute, UMR 1222 INSERM, Paris, France
| | - Diane Le Quang
- Allergology-Anesthesia Department, Hospital of Lyon Sud, Pierre Bénite, France
| | - Pascal Demoly
- Division of Allergy, Department of Pulmonology, University Hospital of Montpellier, and IDESP, UMR UA11, University of Montpellier - INSERM, Montpellier, France
| | - Jean Louis Guéant
- Nancy Regional University Hospital Center, Department of Molecular Medicine and National Center of Inborn Errors of Metabolism, Department of Hepato-gastroenterology, and UMRS 1256 N-GERE (Nutrition-Genetics-Environmental Risks), Institute of Medical Research, University of Lorraine, Vandoeuvre-lès-Nancy, France
| | - Pierre Gillet
- Nancy Regional University Hospital Center, Regional Pharmacovigilance Center, Ingénierie Moléculaire et Ingénierie Articulaire (IMoPA), UMR-7365 CNRS, Faculté de Médecine, University of Lorraine, Vandoeuvre-lès-Nancy, France
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Au EYL, Mak HWF, Yeung MHY, Chiang V, Lam K, Wong JCY, Yeung HHF, Chan EYT, Lau CS, Li PH. Ten-year outcomes of Perioperative Anaphylaxis Workup Study in Hong Kong (PAWS-HK): Performance of diagnostic modalities. Ann Allergy Asthma Immunol 2023:S1081-1206(23)00125-4. [PMID: 36842494 DOI: 10.1016/j.anai.2023.02.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 02/16/2023] [Accepted: 02/17/2023] [Indexed: 02/26/2023]
Abstract
BACKGROUND Studies on perioperative anaphylaxis (PA) in Asia are lacking. Furthermore, allergy workup for PA has largely been limited to the "silver standard" of skin tests (ST). Using in vitro tests as an adjunct to ST may improve and overcome these diagnostic challenges. OBJECTIVE To evaluate the clinical characteristics and diagnostic tests of patients with suspected PA through the Perioperative Anaphylaxis Workup Study in Hong Kong cohort. METHODS Patients with a diagnosis of PA over a 10-year period were recruited into the Perioperative Anaphylaxis Workup Study in Hong Kong. We reviewed the medical records, tryptase elevation, and diagnostic tests including ST, specific immunoglobulin E, and basophil activation tests (BAT). RESULTS In 151 patients with PA, diagnosis was reached in three-fourths of the cases (113/151, 74.8%). The most common culprits identified were neuromuscular blocking agents (25.8%), β lactams (17.2%) and chlorhexidine (13.9%). Severe anaphylaxis was associated with female sex, older age, elevated acute tryptase levels, and more cardiovascular manifestations during induction. Skin tests remained the most sensitive diagnostic modality overall (66.2%). BAT showed better performance for chlorhexidine and gelofusine anaphylaxis, with sensitivity of 80.0% and 79.6%, respectively. Specific Immunoglobulin E indicated even higher sensitivity (95.2%) than did ST (85.0%) and BAT (80.0%) for chlorhexidine anaphylaxis but performed poorly for other drugs. CONCLUSION Neuromuscular blocking agents remain the most common culprit in PA. There was a higher prevalence of gelofusine anaphylaxis in our cohort than was seen in the literature. Skin tests remain the most sensitive testing modality. In vitro tests for chlorhexidine and gelofusine showed promising results, but more studies to further elucidate its use are warranted.
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Affiliation(s)
- Elaine Y L Au
- Division of Clinical Immunology, Department of Pathology Queen Mary Hospital, Hong Kong
| | - Hugo W F Mak
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Maegan H Y Yeung
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Valerie Chiang
- Division of Clinical Immunology, Department of Pathology Queen Mary Hospital, Hong Kong
| | - Ki Lam
- Division of Clinical Immunology, Department of Pathology Queen Mary Hospital, Hong Kong
| | - Jane C Y Wong
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Heather H F Yeung
- Division of Clinical Immunology, Department of Pathology Queen Mary Hospital, Hong Kong
| | - Eric Y T Chan
- Division of Clinical Immunology, Department of Pathology Queen Mary Hospital, Hong Kong
| | - Chak-Sing Lau
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Philip H Li
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong.
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Roy S, Chompunud Na Ayudhya C, Thapaliya M, Deepak V, Ali H. Multifaceted MRGPRX2: New insight into the role of mast cells in health and disease. J Allergy Clin Immunol 2021; 148:293-308. [PMID: 33957166 PMCID: PMC8355064 DOI: 10.1016/j.jaci.2021.03.049] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 03/03/2021] [Accepted: 03/16/2021] [Indexed: 02/07/2023]
Abstract
Cutaneous mast cells (MCs) express Mas-related G protein-coupled receptor-X2 (MRGPRX2; mouse ortholog MrgprB2), which is activated by an ever-increasing number of cationic ligands. Antimicrobial host defense peptides (HDPs) generated by keratinocytes contribute to host defense likely by 2 mechanisms, one involving direct killing of microbes and the other via MC activation through MRGPRX2. However, its inappropriate activation may cause pseudoallergy and likely contribute to the pathogenesis of rosacea, atopic dermatitis, allergic contact dermatitis, urticaria, and mastocytosis. Gain- and loss-of-function missense single nucleotide polymorphisms in MRGPRX2 have been identified. The ability of certain ligands to serve as balanced or G protein-biased agonists has been defined. Small-molecule HDP mimetics that display both direct antimicrobial activity and activate MCs via MRGPRX2 have been developed. In addition, antibodies and reagents that modulate MRGPRX2 expression and signaling have been generated. In this article, we provide a comprehensive update on MrgprB2 and MRGPRX2 biology. We propose that harnessing MRGPRX2's host defense function by small-molecule HDP mimetics may provide a novel approach for the treatment of antibiotic-resistant cutaneous infections. In contrast, MRGPRX2-specific antibodies and inhibitors could be used for the modulation of allergic and inflammatory diseases that are mediated via this receptor.
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Affiliation(s)
- Saptarshi Roy
- Department of Basic and Translational Sciences, University of Pennsylvania, School of Dental Medicine, Philadelphia, Pa
| | - Chalatip Chompunud Na Ayudhya
- Department of Basic and Translational Sciences, University of Pennsylvania, School of Dental Medicine, Philadelphia, Pa
| | - Monica Thapaliya
- Department of Basic and Translational Sciences, University of Pennsylvania, School of Dental Medicine, Philadelphia, Pa
| | - Vishwa Deepak
- Department of Basic and Translational Sciences, University of Pennsylvania, School of Dental Medicine, Philadelphia, Pa
| | - Hydar Ali
- Department of Basic and Translational Sciences, University of Pennsylvania, School of Dental Medicine, Philadelphia, Pa.
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Abstract
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.
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Vitte J, Sabato V, Tacquard C, Garvey LH, Michel M, Mertes PM, Ebo DG, Schwartz LB, Castells MC. Use and Interpretation of Acute and Baseline Tryptase in Perioperative Hypersensitivity and Anaphylaxis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2994-3005. [PMID: 33746087 DOI: 10.1016/j.jaip.2021.03.011] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 03/05/2021] [Accepted: 03/11/2021] [Indexed: 12/18/2022]
Abstract
Paired acute and baseline serum or plasma tryptase sampling and determination have recently been included as a mechanistic approach in the diagnostic and management guidelines of perioperative immediate hypersensitivity and anaphylaxis. The timing of this paired sampling is clearly defined in international consensus statements, with the optimal window for acute tryptase sampling between 30 minutes and 2 hours after the initiation of symptoms, whereas baseline tryptase should be measured in a sample collected before the event (preop) or at least 24 hours after all signs and symptoms have resolved. A transient elevation of the acute tryptase level greater than [2 + (1.2 × baseline tryptase level)] supports the involvement and activation of mast cells. Here, we provide the clinical, pathophysiological, and technical rationale for the procedure and interpretation of paired acute and baseline tryptase. Clinical examples, up-to-date knowledge of hereditary α-tryptasemia as a frequent cause of baseline tryptase of 7 μg/L and higher, mastocytosis, other clonal myeloid disorders, cardiovascular or renal failure, and technical improvements resulting in continued lowering of the 95th percentile value are discussed. Clues for improved management of perioperative immediate hypersensitivity and anaphylaxis include (1) sustained dissemination and implementation of updated guidelines; (2) preoperative sample storage for deferred analysis; (3) referral for thorough allergy investigation, screening for mast cell-related disorders, and recommendations for future anesthetic procedures; and (4) sustained collaboration between anesthesiologists, immunologists, and allergists.
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Affiliation(s)
- Joana Vitte
- Aix-Marseille Univ, IRD, APHM, MEPHI, Marseille, France; IHU Méditerranée Infection, Marseille, France; IDESP, INSERM UMR UA11, University of Montpellier, Montpellier, France
| | - Vito Sabato
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium; AZ Jan Palfijn Gent, Department of Immunology and Allergology, Ghent, Belgium
| | - Charles Tacquard
- Nouvel Hôpital Civil, hôpitaux universitaires de Strasbourg, service d'anesthésie-réanimation chirurgicale, 1, place de l'Hôpital, Strasbourg, France
| | - Lene H Garvey
- Allergy Clinic, Department of Dermatology and Allergy, Gentofte Hospital, Gentofte, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Moïse Michel
- Aix-Marseille Univ, IRD, APHM, MEPHI, Marseille, France; IHU Méditerranée Infection, Marseille, France; Laboratoire d'Immunologie, CHU de Nîmes, Nîmes, France
| | - Paul-Michel Mertes
- Nouvel Hôpital Civil, hôpitaux universitaires de Strasbourg, service d'anesthésie-réanimation chirurgicale, 1, place de l'Hôpital, Strasbourg, France
| | - Didier G Ebo
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium; AZ Jan Palfijn Gent, Department of Immunology and Allergology, Ghent, Belgium
| | - Lawrence B Schwartz
- Department of Internal Medicine, Division of Rheumatology, Allergy & Immunology, Virginia Commonwealth University, Richmond, Va
| | - Mariana C Castells
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass.
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Banerji A, Bhattacharya G, Huebner E, Fu X, Camargo CA, Guyer A, Kuhlen JL, Blumenthal KG. Perioperative Allergic Reactions: Allergy Assessment and Subsequent Anesthesia. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:1980-1991. [PMID: 33248280 DOI: 10.1016/j.jaip.2020.11.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 10/26/2020] [Accepted: 11/09/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Evidence-based guidelines are needed in the United States to improve evaluation of perioperative allergic reactions including recommendations for subsequent anesthesia. OBJECTIVE To identify causative agent(s) and evaluate patients' tolerability of subsequent anesthesia in patients evaluated by Allergy/Immunology (A/I) at Massachusetts General Hospital. METHODS We performed a retrospective review of patients referred to the outpatient A/I clinic for perioperative allergic reactions between October 2003 and May 2017. Patient demographics, atopic history, and prior adverse drug reactions were reviewed. Patients underwent a comprehensive evaluation with testing including skin testing (ST), drug challenges (when appropriate), tryptase level measurement, and specific IgE to latex measurement. Tolerance of subsequent procedures requiring anesthesia was assessed. RESULTS Of 123 patients referred, 74 (60%) were female and the mean age was 46 (±18) years. At least 1 causative agent was identified in 28 patients (24%, n = 28 of 118). Seventeen of 28 (61%) patients were ST positive to an antibiotic, including 13 (46%) positive to cefazolin; 3 patients (11%) had a positive latex specific IgE. Of 85 patients who had subsequent anesthesia with a known outcome, 78 (91%) did not have another perioperative allergic reaction. Two of 5 patients with an elevated baseline tryptase level did not tolerate subsequent anesthesia. CONCLUSION The majority of patients safely received subsequent anesthesia after comprehensive A/I evaluation for their perioperative allergic reactions; however, improved algorithmic care is needed in the United States. Among ST-positive patients (24%), antibiotics (especially cefazolin) were the most common culprits. An elevated baseline tryptase level was associated with an increased risk of recurrent perioperative allergic reactions.
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Affiliation(s)
- Aleena Banerji
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass.
| | - Gita Bhattacharya
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | - Emily Huebner
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | - Xiaoqing Fu
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Mongan Institute, Department of Medicine, Massachusetts General Hospital, 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; Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Mass
| | - Autumn Guyer
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California San Francisco, San Francisco, Calif
| | - James L Kuhlen
- Department of Medicine, Apex Allergy and Immunology, Greenville, SC
| | - 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; Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital, Boston, Mass
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11
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Ansotegui IJ, Melioli G, Canonica GW, Caraballo L, Villa E, Ebisawa M, Passalacqua G, Savi E, Ebo D, Gómez RM, Luengo Sánchez O, Oppenheimer JJ, Jensen-Jarolim E, Fischer DA, Haahtela T, Antila M, Bousquet JJ, Cardona V, Chiang WC, Demoly PM, DuBuske LM, Ferrer Puga M, Gerth van Wijk R, González Díaz SN, Gonzalez-Estrada A, Jares E, Kalpaklioğlu AF, Kase Tanno L, Kowalski ML, Ledford DK, Monge Ortega OP, Morais Almeida M, Pfaar O, Poulsen LK, Pawankar R, Renz HE, Romano AG, Rosário Filho NA, Rosenwasser L, Sánchez Borges MA, Scala E, Senna GE, Sisul JC, Tang ML, Thong BYH, Valenta R, Wood RA, Zuberbier T. IgE allergy diagnostics and other relevant tests in allergy, a World Allergy Organization position paper. World Allergy Organ J 2020; 13:100080. [PMID: 32128023 PMCID: PMC7044795 DOI: 10.1016/j.waojou.2019.100080] [Citation(s) in RCA: 210] [Impact Index Per Article: 52.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 10/08/2019] [Indexed: 02/06/2023] Open
Abstract
Currently, testing for immunoglobulin E (IgE) sensitization is the cornerstone of diagnostic evaluation in suspected allergic conditions. This review provides a thorough and updated critical appraisal of the most frequently used diagnostic tests, both in vivo and in vitro. It discusses skin tests, challenges, and serological and cellular in vitro tests, and provides an overview of indications, advantages and disadvantages of each in conditions such as respiratory, food, venom, drug, and occupational allergy. Skin prick testing remains the first line approach in most instances; the added value of serum specific IgE to whole allergen extracts or components, as well as the role of basophil activation tests, is evaluated. Unproven, non-validated, diagnostic tests are also discussed. Throughout the review, the reader must bear in mind the relevance of differentiating between sensitization and allergy; the latter entails not only allergic sensitization, but also clinically relevant symptoms triggered by the culprit allergen.
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Key Words
- AAAAI, American Academy of Allergy Asthma and Immunology
- ABA, Allergen Bead Array
- ACAAI, American College of Allergy Asthma and Immunology
- AEC, Allergen Exposure Chambers
- AIT, allergen immunotherapy
- AP, Alkaline Phosphatase
- AU/mL, Allergenic Units milliLiter
- Allergy
- Anti-IgE, Antibody against IgE
- BAT, Basophil Activation Test
- BAU/mL, Biologic Allergenic Units milliLiter
- CBA, Cytometric Bead Array
- CCD, Cross-reactive Carbohydrate Determinants
- CDER, Center for Drug Evaluation and Research (USA)
- CL, Chemiluminescence
- CaFE, Calibrated Fluorescence Enhancement
- DBPCFC, Double-Blind Placebo-Controlled Food Challenge
- Diagnostic strategies
- EAACI, European Academy of Allergy and Immunology
- EIA, Enzyme Immune Assay
- ELISA, Enzyme Linked Immuno Sorbent Analysis
- EMEA, European MEdicine Agencies
- ENPP-3, EctoNucleotide Pyrophosphatase/Phosphodiesterase 3
- FACS, Fluorescence-Activated Cell Sorting
- FDA, Food and Drug Administration (U.S. Department of Health and Human Services)
- FEIA, Fluorescent Enzyme Immunoassays
- FcεRI, High affinity IgE receptor
- H1, Histamine 1 receptor
- H2, Histamine 2 receptor
- HPO, Horseradish Peroxidase
- IDT, Intradermal Test
- ISAC, Immuno-Solid phase Allergen Chip
- IUIS, International Union of Immunological Societies
- IVD, in vitro diagnostic tool
- IgE
- IgE, immunoglobulin E
- In vitro tests
- LAMP-3, Lysosomal-Associated Membrane Protein
- MBAD, Molecule Based Allergy Diagnostics
- MRGPRX2, Mas-related G protein receptor 2
- NIH, National Institutes of Health (USA)
- NMBAs, NeuroMuscular Blocking Agents
- NPA, Negative Percent Agreement
- NSAIDs, Non-Steroidal Anti-Inflammatory Drugs
- PPA, Positive Percent Agreement
- PPT, Prick-Prick Test
- RAST, Radio Allergo Sorbent Test
- SCAR, severe cutaneous adverse drug reactions
- SPT, Skin prick test
- Skin tests
- kUA/L, kilo Units of Allergen/Liter for allergen-specific IgE antibody assays
- mAb, Monoclonal Antibody
- pNPP, p-Nitrophenylphosphate
- sIgE, specific IgE
- w/v, weight /volume
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Affiliation(s)
| | - Giovanni Melioli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Giorgio Walter Canonica
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Personalized Medicine, Asthma and Allergy, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Luis Caraballo
- Institute for Immunological Research, University of Cartagena, Cartagena, Colombia
| | - Elisa Villa
- Azienda Sanitaria Locale di Vercelli, S.C. Pneumologia, Vercelli, Italia
| | - Motohiro Ebisawa
- Clinical Research Center for Allergy and Rheumatology, Sagamihara National Hospital, Sagamihara, Kanagawa, Japan
| | - Giovanni Passalacqua
- Allergy and Respiratory Diseases, IRCCS Policlinico San Martino, University of Genoa, Genoa, Italy
| | | | - Didier Ebo
- Department of Immunology - Allergology - Rheumatology, Antwerp University Hospital, Antwerp University, Department Immunology and Allergology, AZ Jan Palfijn Gent, Ghent, Belgium
| | | | - Olga Luengo Sánchez
- Allergy Section, Department of Internal Medicine, Vall d’Hebron University Hospital, Barcelona, Spain
| | | | - Erika Jensen-Jarolim
- Institute for Pathophysiology and Allergy Research, Center of Pathophysiology, Infectiology and Immunology, The Interuniversity Messerli Research Institute, University of Veterinary Medicine Vienna, Medical University Vienna, Vienna, Austria
| | - David A. Fischer
- Fischer Medicine Professional Corporation, Barrie, Ontario, Canada
| | - Tari Haahtela
- Skin and Allergy Hospital, University of Helsinki, Helsinki, Finland
| | | | - Jean J. Bousquet
- MACVIA-France, Montpellier, France
- INSERM, Villejuif, France
- Université Versailles St-Quentin-en-Yvelines, Montigny le Bretonneux, France
- Euforea, Brussels, Belgium
- CHU Montpellier, France
| | - Victoria Cardona
- Universitat Autónoma de Barcelona, Hospital Universitario Vall d'Hebron, Servicio de Medicina Interna, Sección de Alergología, Barcelona, Spain
| | - Wen Chin Chiang
- Mount Elizabeth Medical Centre, Chiang Children's Allergy & Asthma Clinic, Singapore, Singapore
| | - Pascal M. Demoly
- University Hospital Montpellier, Montpellier, France
- Sorbonne Université, Paris, France
| | | | - Marta Ferrer Puga
- The Unidad de Educación Médica, Department of Medical Education, School of Medicine, Clinica Universitad de Navarra, Navarra, Spain
| | | | | | | | | | | | | | - Marek L. Kowalski
- Faculty of Medicine, Department of Clinical Immunology & Allergy, Medical University of Łódź, Łódź, Poland
| | | | | | | | - Oliver Pfaar
- Department of Otorhinolaryngology, Head and Neck Surgery, Section of Rhinology and Allergy, University Hospital Marburg, Philipps-Universität Marburg, Marburg, Germany
| | - Lars K. Poulsen
- Gentofte University Hospital, Lab for Allergology, Allergy Clinic, Hellerup, Denmark
| | - Ruby Pawankar
- Nippon Medical School, Dept. of Otolaryngology, Tokyo, Japan
| | - Harald E. Renz
- University Hospital GI & MR GmbH, Institute of Laboratory Medicine & Pathology, Standort Marburg, Marburg, Germany
| | | | | | - Lanny Rosenwasser
- University of Missouri at Kansas City, School of Medicine, Kansas City, MO, USA
| | | | - Enrico Scala
- Experimental Allergy Unit, Istituto Dermopatico dell'Immacolata, Rome, Italy
| | | | | | - Mimi L.K. Tang
- Royal Children's Hospital, Department of Allergy & Immunology, Parkville, Victoria, Australia
| | - Bernard Yu-Hor Thong
- Tan Tock Seng Hospital, Deptartment of Rheumatology, Allergy & Immunology, Singapore, Singapore
| | - Rudolf Valenta
- Division of Immunopathology, Department of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria
- NRC Institute of Immunology FMBA of Russia, Moscow, Russia
- Laboratory of Immunopathology, Department of Clinical Immunology and Allergy, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Robert A. Wood
- Johns Hopkins University School of Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Torsten Zuberbier
- Campus Charite Mitte, Klinik fur Dermatologie & Allergologie, Berlin, Germany
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12
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Macharadze T, Davies A, Fedor I. A Well-Trained Team During Anaphylactic Shock After Rocuronium in a Patient With Aortic Stenosis: A Case Report. Front Med (Lausanne) 2020; 6:305. [PMID: 31998727 PMCID: PMC6962115 DOI: 10.3389/fmed.2019.00305] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 12/04/2019] [Indexed: 11/13/2022] Open
Abstract
A 66-year-old patient with aortic stenosis was scheduled for an aortic valve replacement and coronary artery bypass surgery. Anesthesia was induced by intravenous injection of midazolam, fentanyl, and propofol. After administration of rocuronium, he developed anaphylactic shock, which was diagnosed by clinical signs, vital parameters, and unresponsiveness to the usual vasopressors. After 30 min of cardiopulmonary resuscitation, the patient survived without any neurological deficits. This case is a reminder that early recognition and treatment of intraoperative hypersensitivity reactions are imperative. Anesthetists should also receive simulation training to achieve an adequate experience in a safe environment. With a well-trained team, it is possible to save the life of patients with aortic stenosis.
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Affiliation(s)
- Tamar Macharadze
- Cardiothoracic Critical Care Unit, Wythenshawe Hospital Manchester University, Manchester, United Kingdom.,Department of Molecular Biology, Davit Tvildiani Medical University, Tbilisi, Georgia
| | - Andrew Davies
- Cardiothoracic Critical Care Unit, Wythenshawe Hospital Manchester University, Manchester, United Kingdom
| | - Igor Fedor
- Cardiothoracic Critical Care Unit, Wythenshawe Hospital Manchester University, Manchester, United Kingdom
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13
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Garvey LH, Ebo DG, Mertes P, Dewachter P, Garcez T, Kopac P, Laguna JJ, Chiriac AM, Terreehorst I, Voltolini S, Scherer K. An EAACI position paper on the investigation of perioperative immediate hypersensitivity reactions. Allergy 2019; 74:1872-1884. [PMID: 30964555 DOI: 10.1111/all.13820] [Citation(s) in RCA: 114] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Accepted: 03/19/2019] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Lene Heise Garvey
- Danish Anaesthesia Allergy Centre, Allergy Clinic, Department of Dermatology and Allergy Copenhagen University Hospital Gentofte Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
| | - Didier G. Ebo
- Faculty of Medicine and Health Science, Department of Immunology – Allergology – Rheumatology Antwerp University Hospital, University of Antwerp Antwerp Belgium
| | - Paul‐Michel Mertes
- Department of Anesthesia and Intensive Care Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, EA 3072, FMTS de Strasbourg Strasbourg France
| | - Pascale Dewachter
- Service d’Anesthésie‐Réanimation, Groupe Hospitalier de Paris‐Seine‐Saint‐Denis Assistance Publique‐Hôpitaux de Paris & Université Paris 13, Sorbonne Paris Cité Paris France
| | - Tomaz Garcez
- Immunology Department Manchester University NHS Foundation Trust Manchester UK
| | - Peter Kopac
- University Clinic of Respiratory and Allergic Diseases Golnik Slovenia
| | - José Julio Laguna
- Allergy Unit, Allergo‐Anaesthesia Unit, Faculty of Medicine Hospital Central de la Cruz Roja, Alfonso X El Sabio University, ARADyAL Madrid Spain
| | - Anca Mirela Chiriac
- Allergy Unit, Département de Pneumologie et Addictologie, Hôpital Arnaud de Villeneuve University Hospital of Montpellier Montpellier France
- Sorbonnes Universités, UPMC Paris 06, UMR‐S 1136, IPLESP, Equipe EPAR Paris France
| | - Ingrid Terreehorst
- Department of ENT and DPAC AUMCAmsterdam University Medical Center Amsterdam The Netherlands
| | | | - Kathrin Scherer
- Allergy Unit, Department of Dermatology, University Hospital University of Basel Basel Switzerland
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14
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Integrating basophil activation tests into evaluation of perioperative anaphylaxis to neuromuscular blocking agents. Br J Anaesth 2019; 123:e135-e143. [DOI: 10.1016/j.bja.2019.02.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 02/07/2019] [Accepted: 02/24/2019] [Indexed: 01/11/2023] Open
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15
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Takazawa T, Sabato V, Ebo DG. In vitro diagnostic tests for perioperative hypersensitivity, a narrative review: potential, limitations, and perspectives. Br J Anaesth 2019; 123:e117-e125. [DOI: 10.1016/j.bja.2019.01.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 12/25/2018] [Accepted: 01/03/2019] [Indexed: 12/28/2022] Open
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16
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Bensghir M, Atmani M, Elwali A, Azendour H, Kamili ND. Successful treatment by vasopressin of a refractory rocuronium-induced anaphylactic shock: Case report. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2012.12.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Mustapha Bensghir
- Department of Anesthesiology, Military Hospital Med V Rabat , University of Med V Souissi , Rabat, Morocco
| | - Mohamed Atmani
- Department of Anesthesiology, Military Hospital Med V Rabat , University of Med V Souissi , Rabat, Morocco
| | - Abderhmane Elwali
- Department of Anesthesiology, Military Hospital Med V Rabat , University of Med V Souissi , Rabat, Morocco
| | - Hicham Azendour
- Department of Anesthesiology, Military Hospital Med V Rabat , University of Med V Souissi , Rabat, Morocco
| | - Noureddine Drissi Kamili
- Department of Anesthesiology, Military Hospital Med V Rabat , University of Med V Souissi , Rabat, Morocco
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17
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Comparative epidemiology of suspected perioperative hypersensitivity reactions. Br J Anaesth 2019; 123:e16-e28. [PMID: 30916015 DOI: 10.1016/j.bja.2019.01.027] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 12/24/2018] [Accepted: 01/15/2019] [Indexed: 12/31/2022] Open
Abstract
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.
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18
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Cisatracurium induces mast cell activation and pseudo-allergic reactions via MRGPRX2. Int Immunopharmacol 2018; 62:244-250. [PMID: 30032049 DOI: 10.1016/j.intimp.2018.07.020] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 07/09/2018] [Accepted: 07/15/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Pseudo-allergic reactions occur when patients receive muscle relaxants during perioperative anesthesia. These reactions may result in a serious threat to the patient's life, particularly to a child's life. Cisatracurium, a relatively new NMBA, has resulted in bronchospasms and cardiovascular collapse. However, the mechanisms underlying the anaphylactoid reactions caused by cisatracurium have not been fully elucidated. METHODS In the present study, the MRGPRX2-related pseudo-allergic reactions induced by cisatracurium were investigated using hindpaw swelling and extravasation assays in vivo and mast cell degranulation assays. RESULTS Cisatracurium caused anaphylactoid reactions in wild-type mice. However, cisatracurium did not induce a similar phenomenon in KitW-sh/W-sh mice. Furthermore, mast cell-related G protein-coupled receptor B2-knockout mice did not display an inflammatory response upon treatment with cisatracurium. Cisatracurium induced LAD2 cell degranulation, leading to the dose-dependent release of β-hexosaminidase, histamine and TNF-α. However, cisatracurium only induced the release of low levels of these mediator LAD2 cells transfected with MRGPRX2 siRNA. Cisatracurium also stimulated intracellular Ca2+ influx in MRGPRX2-HEK293 cells compared with that in NC-HKE293 cells. Interestingly, cytokine release was not observed in LAD2 cells even with high dose of cisatracurium. CONCLUSIONS Cisatracurium activated MRGPRX2 and triggered mast cell degranulation, leading to anaphylactoid reactions. Therefore, strategies targeting MRGPRX2 might potentially block cisatracurium-induced pseudo-allergic reactions.
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19
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Garvey L, Hunter J. Changing culprits in perioperative anaphylaxis. Br J Anaesth 2018; 121:114-117. [DOI: 10.1016/j.bja.2018.05.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Accepted: 05/08/2018] [Indexed: 12/20/2022] Open
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20
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Anaesthesia, surgery, and life-threatening allergic reactions: epidemiology and clinical features of perioperative anaphylaxis in the 6th National Audit Project (NAP6). Br J Anaesth 2018; 121:159-171. [DOI: 10.1016/j.bja.2018.04.014] [Citation(s) in RCA: 290] [Impact Index Per Article: 48.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 03/30/2018] [Accepted: 04/13/2018] [Indexed: 12/25/2022] Open
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21
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Turner PJ, Jerschow E, Umasunthar T, Lin R, Campbell DE, Boyle RJ. Fatal Anaphylaxis: Mortality Rate and Risk Factors. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 5:1169-1178. [PMID: 28888247 PMCID: PMC5589409 DOI: 10.1016/j.jaip.2017.06.031] [Citation(s) in RCA: 285] [Impact Index Per Article: 47.5] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 06/01/2017] [Accepted: 06/20/2017] [Indexed: 12/21/2022]
Abstract
Up to 5% of the US population has suffered anaphylaxis. Fatal outcome is rare, such that even for people with known venom or food allergy, fatal anaphylaxis constitutes less than 1% of total mortality risk. The incidence of fatal anaphylaxis has not increased in line with hospital admissions for anaphylaxis. Fatal drug anaphylaxis may be increasing, but rates of fatal anaphylaxis to venom and food are stable. Risk factors for fatal anaphylaxis vary according to cause. For fatal drug anaphylaxis, previous cardiovascular morbidity and older age are risk factors, with beta-lactam antibiotics, general anesthetic agents, and radiocontrast injections the commonest triggers. Fatal food anaphylaxis most commonly occurs during the second and third decades. Delayed epinephrine administration is a risk factor; common triggers are nuts, seafood, and in children, milk. For fatal venom anaphylaxis, risk factors include middle age, male sex, white race, cardiovascular disease, and possibly mastocytosis; insect triggers vary by region. Upright posture is a feature of fatal anaphylaxis to both food and venom. The rarity of fatal anaphylaxis and the significant quality of life impact of allergic conditions suggest that quality of life impairment should be a key consideration when making treatment decisions in patients at risk for anaphylaxis.
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Affiliation(s)
- Paul J Turner
- Department of Paediatric Allergy, Imperial College London, London, United Kingdom; Department of Allergy and Immunology, University of Sydney, Sydney, Australia
| | - Elina Jerschow
- Division of Allergy and Immunology, Albert Einstein College of Medicine, Bronx, NY
| | | | - Robert Lin
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Dianne E Campbell
- Department of Allergy and Immunology, University of Sydney, Sydney, Australia; Department of Allergy and Immunology, Children's Hospital at Westmead, Sydney, Australia
| | - Robert J Boyle
- Department of Paediatric Allergy, Imperial College London, London, United Kingdom.
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22
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de Pater GH, Florvaag E, Johansson SGO, Irgens Å, Petersen MNH, Guttormsen AB. Six years without pholcodine; Norwegians are significantly less IgE-sensitized and clinically more tolerant to neuromuscular blocking agents. Allergy 2017; 72:813-819. [PMID: 27859358 DOI: 10.1111/all.13081] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND As a strong inducer of IgE antibodies to substituted ammonium ion epitopes (QAI), pholcodine (PHO) is a postulated cause of allergic anaphylaxis to neuromuscular blocking agents (NMBAs). Three years after withdrawal of PHO in Norway, a significant reduction in IgE sensitization and anaphylaxis reporting was seen. OBJECTIVE Six-year follow-up study on the effects of PHO withdrawal on IgE sensitization and anaphylaxis reporting. METHODS From 650 acute consecutive reports (2005-2013) to the Norwegian Network for Anaphylaxis under Anaesthesia (NARA), total number of reports on suspected anaphylactic reactions, number of reactions where NMBAs were administered, number of reactions where serum IgE antibodies (≥0.35 kUA /l) to suxamethonium (SUX) and PHO were present at time of reaction and anaphylaxis severity grades were retrieved. In addition, NMBA sales and prevalence of IgE sensitization to PHO and SUX among 'allergics' were monitored. RESULTS From baseline period P0 (PHO on the market) through the first (P1) and second (P2), three-year periods after withdrawal, significant falls in total reports (P < 0.001) and reports with IgE antibodies to PHO (P = 0.008) and SUX (P = 0.001) at time of reaction were found. Total NMBA sales in P2 were 83% of P0, and SUX and rocuronium (ROC) together made up 86% of sales throughout the study. Five NMBA-related anaphylactic deaths occurred during P0 and P1 and, however, none during P2. Prevalence of IgE sensitization to SUX in 'allergics' fell to 0% at 4 and 5 years after withdrawal. CONCLUSIONS Six years after PHO withdrawal, the Norwegian population has become significantly less IgE-sensitized and clinically more tolerant to NMBAs.
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Affiliation(s)
- G. H. de Pater
- Department of Anaesthesia and Intensive Care; Haukeland University Hospital; Bergen Norway
| | - E. Florvaag
- Laboratory of Clinical Biochemistry; Haukeland University Hospital; Bergen Norway
- Department of Occupational Medicine; Haukeland University Hospital; Bergen Norway
- Department of Clinical Science; University of Bergen; Bergen Norway
| | - S. G. O. Johansson
- Department of Medicine; Clinical Immunology and Allergy Unit; Karolinska Institute; Stockholm Sweden
- Department of Clinical Immunology and Transfusion Medicine; Karolinska University Hospital; Stockholm Sweden
| | - Å. Irgens
- Department of Occupational Medicine; Haukeland University Hospital; Bergen Norway
| | - M. N. H. Petersen
- Department of Anaesthesia and Intensive Care; Haukeland University Hospital; Bergen Norway
| | - A. B. Guttormsen
- Department of Anaesthesia and Intensive Care; Haukeland University Hospital; Bergen Norway
- Department of Clinical Medicine; Section of Anaesthesiology and Intensive Care; University of Bergen; Bergen Norway
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Mertes PM, Florvaag E. Anaphylaxis in the operating theatre. Presse Med 2017; 45:750-2. [PMID: 27666588 DOI: 10.1016/j.lpm.2016.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Affiliation(s)
- Paul-Michel Mertes
- Hôpitaux universitaires de Strasbourg, Nouvel hôpital civil, service d'anesthésie-réanimation chirurgicale, 1, place de l'Hôpital, BP 426, 67091 Strasbourg cedex, France.
| | - Erik Florvaag
- Haukeland university hospital, regional centre for asthma, allergy and hypersensitivity, department of occupational medicine, 5021 Bergen, Norway.
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24
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Trautmann A, Seidl C, Stoevesandt J, Seitz CS. General anaesthesia-induced anaphylaxis: impact of allergy testing on subsequent anaesthesia. Clin Exp Allergy 2016; 46:125-32. [PMID: 26767493 DOI: 10.1111/cea.12632] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2015] [Revised: 08/25/2015] [Accepted: 08/28/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Immunoglobulin E-mediated allergy to drugs and substances used during general anaesthesia as well as non-allergic drug hypersensitivity reactions may account for anaesthesia-induced anaphylaxis. As IgE-mediated anaphylaxis is a potentially life-threatening reaction, identification of the culprit allergen is essential to avoid anaphylaxis recurrence during subsequent general anaesthesia. OBJECTIVE To study whether preventive recommendations derived from allergy testing after intraoperative anaphylaxis were followed in subsequent general anaesthesia. METHODS Results of standardized allergy testing after anaesthesia-induced anaphylaxis and outcome of subsequent general anaesthesia were analysed retrospectively. RESULTS Fifty-three of 107 patients were diagnosed with IgE-mediated allergy to a drug or substance used during general anaesthesia, and 54 patients were test negative. Twenty-eight of 29 allergy patients tolerated subsequent general anaesthesia uneventfully. One patient with cefazolin allergy suffered from anaphylaxis recurrence due to accidental reapplication of cefazolin. Twenty-two of 24 test-negative patients tolerated subsequent general anaesthesia, whereas two patients again developed anaphylaxis despite pre-medication regimens. CONCLUSION AND CLINICAL RELEVANCE Our results confirm the practical impact of allergy testing in general anaesthesia-induced anaphylaxis. By identification of the allergen, it is possible to avoid allergic anaphylaxis during subsequent anaesthesia. In most cases, recommended pre-medication seems to prevent the recurrence of non-allergic drug hypersensitivity reactions.
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Affiliation(s)
- A Trautmann
- Department of Dermatology and Allergy, University Hospital Würzburg, Würzburg, Germany
| | - C Seidl
- Department of Dermatology and Allergy, University Hospital Würzburg, Würzburg, Germany
| | - J Stoevesandt
- Department of Dermatology and Allergy, University Hospital Würzburg, Würzburg, Germany
| | - C S Seitz
- Department of Dermatology and Allergy, University Hospital Göttingen, Göttingen, Germany
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25
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Tacquard C, Laroche D, Stenger R, Mariotte D, Uring-Lambert B, De Blay F, Malinovsky JM, Mertes PM. Diagnostic procedure after an immediate hypersensitivity reaction in the operating room. Presse Med 2016; 45:784-90. [PMID: 27374263 DOI: 10.1016/j.lpm.2016.05.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
The diagnosis of a perioperative allergic reaction is based on clinical features associated with a suggestive timeline, the exclusion of other diagnoses, elevated concentrations of degranulation markers (histamine, tryptase), and positive allergy assessments (skin tests, specific IgE). After initiating appropriate treatment, the anesthesiologist should take blood samples to measure histamine and tryptase concentrations just after the reaction and repeat them 1-2hours later to validate the diagnosis of immediate hypersensitivity. A delayed measurement of basal tryptase is useful to rule out mastocytosis and to interpret moderate tryptase levels. The anesthesiologist must inform the patient of the reaction to obtain adhesion and consent to subsequent investigations and must record the timing of the reaction and of the blood sampling, the possible causal agents, and the treatment administered. These data must be shared with the laboratory and the allergist. An adverse drug reaction report must be filed. The gold standard for allergy assessment is skin testing. These tests should be done in an appropriate facility, with experienced staff and in compliance with current guidelines. Specific IgE assays and cellular assays can help when clinical features and skin tests are discordant. Provocation tests are sometimes required. After allergy assessment, the safest protocol for subsequent anesthesia is determined in collaboration with the anesthesiologist. The patient must be informed and carry an allergy alert card.
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Affiliation(s)
- Charles Tacquard
- Hôpitaux universitaires de Strasbourg, département d'anesthésie-réanimation, 67000 Strasbourg, France.
| | | | - Rodolphe Stenger
- Hôpitaux universitaires de Strasbourg, université de Strasbourg, pôle de pathologie thoracique, fédération de médecine translationnelle, 67000 Strasbourg, France
| | | | - Béatrice Uring-Lambert
- Hôpitaux universitaires de Strasbourg, laboratoire central d'immunologie, 67000 Strasbourg, France
| | - Frédéric De Blay
- Hôpitaux universitaires de Strasbourg, université de Strasbourg, pôle de pathologie thoracique, fédération de médecine translationnelle, 67000 Strasbourg, France
| | - Jean-Marc Malinovsky
- CHU de Reims, hôpital Maison-Blanche, département d'anesthésie-réanimation, 51100 Reims, France
| | - Paul Michel Mertes
- Hôpitaux universitaires de Strasbourg, département d'anesthésie-réanimation, 67000 Strasbourg, France
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Spoerl D, D'Incau S, Roux-Lombard P, Harr T, Czarnetzki C. Non-IgE-Dependent Hypersensitivity to Rocuronium Reversed by Sugammadex: Report of Three Cases and Hypothesis on the Underlying Mechanism. Int Arch Allergy Immunol 2016; 169:256-62. [PMID: 27240836 DOI: 10.1159/000446182] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 04/12/2016] [Indexed: 11/19/2022] Open
Abstract
We present 3 cases of pseudoallergic (anaphylactoid) reactions to perioperatively administered rocuronium, which rapidly resolved after sugammadex injection. Allergological workup showed no evidence for immediate-type hypersensitivity to the drugs used for anesthesia, including rocuronium. However, rocuronium induced an irritative reaction in skin tests in all 3 patients and in 3 healthy individuals. This reaction was specifically suppressed by adding sugammadex at a 1:1 molecular proportion to rocuronium before the skin tests. This observation suggests that the patients suffered from a pseudoallergic reaction, and indicates that sugammadex might act via the inhibition of non-IgE mediated MRGPRX2 (Mas-related G-protein-coupled receptor member X2)-triggered mast cell degranulation induced by rocuronium.
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Affiliation(s)
- David Spoerl
- Division of Clinical Immunology and Allergy, Department of Medical Specialties, Geneva University Hospital, Geneva, Switzerland
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Perioperative Hypersensitivity Reactions: Diagnosis, Treatment and Evaluation. CURRENT TREATMENT OPTIONS IN ALLERGY 2016. [DOI: 10.1007/s40521-016-0078-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Lieberman P, Nicklas RA, Randolph C, Oppenheimer J, Bernstein D, Bernstein J, Ellis A, Golden DBK, Greenberger P, Kemp S, Khan D, Ledford D, Lieberman J, Metcalfe D, Nowak-Wegrzyn A, Sicherer S, Wallace D, Blessing-Moore J, Lang D, Portnoy JM, Schuller D, Spector S, Tilles SA. Anaphylaxis--a practice parameter update 2015. Ann Allergy Asthma Immunol 2016; 115:341-84. [PMID: 26505932 DOI: 10.1016/j.anai.2015.07.019] [Citation(s) in RCA: 299] [Impact Index Per Article: 37.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 07/12/2015] [Indexed: 12/12/2022]
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Takazawa T, Mitsuhata H, Mertes PM. Sugammadex and rocuronium-induced anaphylaxis. J Anesth 2015; 30:290-7. [PMID: 26646837 PMCID: PMC4819478 DOI: 10.1007/s00540-015-2105-x] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Accepted: 11/11/2015] [Indexed: 12/19/2022]
Abstract
Perioperative anaphylaxis is a life-threatening clinical condition that is typically the result of drugs or substances used for anesthesia or surgery. The most common cause of anaphylaxis during anesthesia is reportedly neuromuscular blocking agents. Of the many muscle relaxants that are clinically available, rocuronium is becoming popular in many countries. Recent studies have demonstrated that succinylcholine (but also rocuronium use) is associated with a relatively high rate of IgE-mediated anaphylaxis compared with other muscle relaxant agents. Sugammadex is widely used for reversal of the effects of steroidal neuromuscular blocking agents, such as rocuronium and vecuronium. Confirmed cases of allergic reactions to clinical doses of sugammadex have also been recently reported. Given these circumstances, the number of cases of hypersensitivity to either sugammadex or rocuronium is likely to increase. Thus, anesthesiologists should be familiar with the epidemiology, mechanisms, and clinical presentations of anaphylaxis induced by these drugs. In this review, we focus on the diagnosis and treatment of anaphylaxis to sugammadex and neuromuscular blocking agents. Moreover, we discuss recent studies in this field, including the diagnostic utility of flow cytometry and improvement of rocuronium-induced anaphylaxis with the use of sugammadex.
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Affiliation(s)
- Tomonori Takazawa
- Department of Anesthesiology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, 371-8511, Japan.
| | - Hiromasa Mitsuhata
- Department of Anesthesiology, Juntendo Tokyo Koto Geriatric Medical Center, 3-3-20 Shinsuna, Koto-Ku, Tokyo, 136-0075, Japan
| | - Paul Michel Mertes
- Service d'anesthésie-réanimation chirurgicale, Nouvel hôpital civil, hôpitaux universitaires de Strasbourg, 1, place de l'Hôpital, BP 426, 67091, Strasbourg Cedex, France
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Low AE, McEwan JC, Karanam S, North J, Kong KL. Anaesthesia-associated hypersensitivity reactions: seven years' data from a British bi-specialty clinic. Anaesthesia 2015; 71:76-84. [PMID: 26566603 DOI: 10.1111/anae.13273] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2015] [Indexed: 11/27/2022]
Affiliation(s)
- A. E. Low
- Department of Anaesthesia; Sandwell and West Birmingham Hospitals; Birmingham UK
| | - J. C. McEwan
- Department of Anaesthesia; Sandwell and West Birmingham Hospitals; Birmingham UK
| | - S. Karanam
- Department of Immunology; Sandwell and West Birmingham Hospitals; Birmingham UK
| | - J. North
- Department of Immunology; Sandwell and West Birmingham Hospitals; Birmingham UK
| | - K-L. Kong
- Department of Anaesthesia; Sandwell and West Birmingham Hospitals; Birmingham UK
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Abstract
Perioperative anaphylaxis is a unique condition as a result of the additive cardiovascular effects of anesthetics on the cardiovascular disturbances of anaphylaxis. It occurs mainly in adulthood, primarily follows anesthetic induction, and for the most part, is an IgE-mediated pathomechanism. Neuromuscular blocking agents (NMBAs) and antibiotics are the main culprit drugs, while latex is now infrequently involved. The Ring and Messmer scale is a useful tool for demonstrating the clinical severity of perioperative immediate hypersensitivity and guiding its management. Grades III and IV are life-threatening and are referred to as anaphylaxis. Three different clinical patterns of grade III may be observed, where cardiovascular collapse is the cardinal sign. Grade IV presents as cardiac arrest. The initial diagnosis is presumptive, whereas the etiological assessment is linked to the clinical presentation, tryptase levels, and skin test results. Since anaphylaxis presents with significant hypovolemia and vasoplegia, aggressive fluid therapy and epinephrine are the cornerstones of management. Whenever possible, anesthetic discontinuation is also recommended. Scientific evidence in favor of preemptive therapeutic strategies to prevent anaphylaxis in the operative setting is lacking.
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Brusch AM, Clarke RC, Platt PR, Phillips E. Response to letter regarding article 'Exploring the link between pholcodine exposure and neuromuscular blocking agent anaphylaxis'. Br J Clin Pharmacol 2015; 78:931-2. [PMID: 24611979 DOI: 10.1111/bcp.12375] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 03/02/2014] [Indexed: 11/29/2022] Open
Affiliation(s)
- Anna M Brusch
- Department of Clinical Immunology, Fremantle Hospital, Fremantle, WA, Australia
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Brusch AM, Clarke RC, Platt PR, Phillips EJ. Exploring the link between pholcodine exposure and neuromuscular blocking agent anaphylaxis. Br J Clin Pharmacol 2015; 78:14-23. [PMID: 24251966 DOI: 10.1111/bcp.12290] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Accepted: 10/15/2013] [Indexed: 11/26/2022] Open
Abstract
Neuromuscular blocking agents (NMBAs) are the most commonly implicated drugs in IgE-mediated anaphylaxis during anaesthesia that can lead to perioperative morbidity and mortality. The rate of NMBA anaphylaxis shows marked geographical variation in patients who have had no known prior exposure to NMBAs, suggesting that there may be external or environmental factors that contribute to the underlying aetiology and pathophysiology of reactions. Substituted ammonium ions are shared among NMBAs and are therefore thought to be the main allergenic determinant of this class of drugs. Substituted ammonium ions are found in a wide variety of chemical structures, including prescription medications, over-the-counter medications and common household chemicals, such as the quaternary ammonium disinfectants. Epidemiological studies have shown parallels in the consumption of pholcodine, a nonprescription antitussive drug which contains a tertiary ammonium ion, and the incidence of NMBA anaphylaxis. This link has prompted the withdrawal of pholcodine in some countries, with an ensuing fall in the observed rate of NMBA anaphylaxis. While such observations are compelling in their suggestion of a relationship between pholcodine exposure and NMBA hypersensitivity, important questions remain regarding the mechanisms by which pholcodine is able to sensitize against NMBAs and whether there are other, as yet unidentified, agents that can elicit similar hypersensitivity reactions. This review aims to explore the evidence linking pholcodine exposure to NMBA hypersensitivity and discuss the implications for our understanding of the pathophysiology of these reactions.
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Affiliation(s)
- Anna M Brusch
- Department of Clinical Immunology, Fremantle Hospital, Fremantle, WA, Australia; Sir Charles Gairdner Hospital, Perth, WA, Australia
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Anaphylaxis is more common with rocuronium and succinylcholine than with atracurium. Anesthesiology 2015; 122:39-45. [PMID: 25405395 DOI: 10.1097/aln.0000000000000512] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Intraoperative anaphylaxis is a rare but serious occurrence, often triggered by neuromuscular-blocking drugs (NMBDs). Previous reports suggest that the rates of anaphylaxis may be greater for rocuronium than for other NMBDs, but imprecise surrogate metrics for new patient exposures to NMBDs complicate interpretation. METHODS This was a retrospective, observational cohort study of intraoperative anaphylaxis to NMBDs at two hospitals between 2006 and 2012. Expert anesthetic and immunologist collaborators investigated all referred cases of intraoperative anaphylaxis where NMBDs were administered and identified those where a NMBD was considered responsible. New patient exposures for each NMBD were extracted from electronic anesthetic records compiled during the same period. Anaphylaxis rates were calculated for each NMBD using diagnosed anaphylaxis cases as the numerator and the number of new patient exposures as the denominator. RESULTS Twenty-one patients were diagnosed with anaphylaxis to an NMBD. The incidence of anaphylaxis was 1 in 22,451 new patient exposures for atracurium, 1 in 2,080 for succinylcholine, and 1 in 2,499 for rocuronium (P < 0.001). CONCLUSIONS In Auckland, the rate of anaphylaxis to succinylcholine and rocuronium is approximately 10-fold higher than to atracurium. Previous estimates of NMBD anaphylaxis rates are potentially confounded by inaccurate proxies of new patient exposures. This is the first study to report anaphylaxis rates using a hard denominator of new patient exposures obtained directly from anesthetic records.
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Abstract
Abstract
Background:
Previously reported incidences for intraoperative hypersensitivity reactions vary more than 15-fold. The goal was to determine the incidence of intraoperative hypersensitivity events at a U.S. surgical center.
Methods:
With institutional review board (Cleveland, Ohio) approval and waiver of written/informed consent, the anesthesia records of adult patients undergoing noncardiac surgery from 2005 to 2011 at the Cleveland Clinic were queried using a novel electronic search protocol developed to identify potential hypersensitivity reactions: cardiovascular collapse defined as systolic arterial blood pressure less than 50 mmHg; administration of epinephrine; administration of diphenhydramine; physician comments in the anesthesia record suggestive of hypersensitivity reactions; laboratory tests for histamine, tryptase, or immunoglobulin-E within 24 h of surgery; and International Classification of Diseases, Ninth Revision, codes suggestive of hypersensitivity reactions. Each electronically identified candidate chart was evaluated by an adjudication committee. Hypersensitivity reactions were graded on a 5-point severity scale. From these data, the authors determined the proportion of operations having adjudicated hypersensitivity reactions, and calculated the 95% exact binomial CI.
Results:
Among 178,746 records, 4,008 charts were identified by the search strategies. After adjudication, 264 hypersensitivity cases were identified. The overall incidence of hypersensitivity reactions was 1:677 surgeries, corresponding to 15 (95% CI, 13 to 17) cases per 10,000 operations. The incidence of severe hypersensitivity reactions (grades 3 to 5) was 1:4,583, corresponding to 2 (95% CI, 2 to 3) cases per 10,000 operations.
Conclusions:
The incidence of severe hypersensitivity reactions was similar to previous reports. However, the overall incidence of hypersensitivity reactions was much greater than reported elsewhere, possibly because of a comprehensive search strategy.
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Perioperative anaphylactic reactions: Review and procedure protocol in paediatrics. Allergol Immunopathol (Madr) 2015; 43:203-14. [PMID: 24231150 DOI: 10.1016/j.aller.2013.07.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Accepted: 07/20/2013] [Indexed: 11/21/2022]
Abstract
Perioperative anaphylactic reactions are immediate, hypersensitive reactions that are potentially life-threatening resulting from a sudden release of mediators from mast cells and basophiles, due to either immune (IgE or non-IgE mediated) or non-immune mechanisms. The most frequent causing agents are neuromuscular blocking agents (NMBAs), latex and antibiotics, with latex being the first cause in paediatrics. With regard to perioperative anaphylactic reactions, the usual early signs and symptoms of an anaphylactic reaction could be overlooked or erroneously interpreted and non-severe anaphylaxis could go undetected, with a risk of more severe reactions in the future. Using the data registered on the anaesthesia sheet, it is essential to establish a chronological relationship between drugs and/or substances administered and the reaction observed. An elevated level of tryptase confirms an anaphylactic reaction, but this does not usually increase in the absence of compromised circulation. An allergy study should be carried out preferably between 4 and 6 weeks after the reaction, using a combination of specific IgE, skin and controlled exposure tests (if indicated). Test sensitivity is good for NMBAs, latex, antibiotics, chlorhexidine, gelatine and povidone, and poor for barbiturates, opiates (these can give false positives since they are histamine releasers) and benzodiazepines. Special preventive measures should be taken, especially in the case of latex. We present the maximum concentrations recommended for skin tests, the recommended dosage to treat anaphylactic reactions in paediatrics and a procedure algorithm for the allergological study of these reactions.
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Kannan JA, Bernstein JA. Perioperative anaphylaxis: diagnosis, evaluation, and management. Immunol Allergy Clin North Am 2015; 35:321-34. [PMID: 25841554 DOI: 10.1016/j.iac.2015.01.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Perioperative anaphylaxis can occur during or after surgery and can have life-threatening consequences. As anesthesia protocols become more complex and incorporate multiple agents to regulate physiologic processes intraoperatively, perioperative anaphylaxis is becoming increasingly recognized. The allergist should obtain detailed records from the anesthesiologist in order to perform appropriate testing to identify the likely causative agents. Testing should ideally be performed 4 to 6 weeks after the reaction to account for a refractory period after mast cell activation. This article includes 2 cases of perioperative anaphylaxis and reviews the historical elements that must be considered after a reaction has occurred.
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Affiliation(s)
- Jennifer A Kannan
- Division of Immunology, Allergy and Rheumatology, Department of Medicine, University of Cincinnati College of Medicine, 3255 Eden Avenue, Suite 350, ML 563, Cincinnati, OH 45267-0563, USA
| | - Jonathan A Bernstein
- Division of Immunology, Allergy and Rheumatology, Department of Medicine, University of Cincinnati College of Medicine, 3255 Eden Avenue, Suite 350, ML 563, Cincinnati, OH 45267-0563, USA; Bernstein Clinical Research Center, 8444 Winton Road, Cincinnati, OH 45231, USA.
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Abstract
Perioperative anaphylaxis is a life-threatening condition with an estimated prevalence of 1:3,500 to 1:20,000 procedures and a mortality rate of up to 9 %. Clinical presentation involves signs such as skin rash, urticaria, angioedema, bronchospasm, tachycardia, bradycardia, and hypotension. Prompt recognition and treatment is of utmost importance to the patient's prognosis, since clinical deterioration can develop rapidly. Epinephrine is the main treatment drug, and its use should not be postponed, since delayed administration is associated with increased mortality. Elevated levels of serum tryptase help to confirm the diagnosis. The main agents involved in IgE-mediated perioperative anaphylaxis are neuromuscular blocking agents, latex, antibiotics, hypnotics, opioids, and colloids. Specific investigation should be conducted 4 to 6 weeks after the reaction and relies on skin tests, serum-specific IgE, and challenge procedures. This review aims to discuss the main aspects of perioperative anaphylaxis: risk factors, diagnosis, treatment, culprit agents, specific investigation, and preventive measures.
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Katelaris CH, Kurosawa M, Moon HB, Borres M, Florvaag E, Johansson SGO. Pholcodine consumption and immunoglobulin E-sensitization in atopics from Australia, Korea, and Japan. Asia Pac Allergy 2014; 4:86-90. [PMID: 24809013 PMCID: PMC4005347 DOI: 10.5415/apallergy.2014.4.2.86] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Accepted: 04/11/2014] [Indexed: 11/30/2022] Open
Abstract
Background Accumulating data indicates that pholcodine (PHO)-consuming countries have higher sero-prevalences of immunoglobulin E (IgE)-antibodies to PHO and suxamethonium (SUX) and increased frequencies of IgE-mediated anaphylaxis to neuromuscular blocking agents (NMBAs) than nonconsuming. Withdrawing PHO-containing cough syrups resulted in a significant decrease of cases with anaphylaxis in Scandinavia. Nevertheless, the European Medicines Agency in 2011 advised to continue the unrestricted use throughout the European Union. Objective To extend studies on PHO consumption and prevalence of IgE-sensitization to morphine (MOR), PHO, and SUX to countries representing high (Australia), and low (Korea and Japan), consumers, respectively. Methods IgE-antibodies to SUX, MOR, and PHO in atopic subjects were determined by immunoassay and compared with official figures for PHO consumption and reported anaphylaxis to NMBA. Results The prevalences of IgE-antibodies to PHO, MOR, and SUX were 10%, 8.6%, and 4.3%, respectively, in Australia. The corresponding figures for Japan were 0.8%, 0.8%, and 1.5%, and for Korea 1.0% to PHO and 0.5% to MOR and SUX. Of the SUX-positive sera, 100% were positive to PHO or MOR in Australia and 0% in Japan and Korea. Conclusion The study supports previous findings; exposure to PHO may induce IgE-antibodies to the substituted ammonium ion epitope of NMBAs, thus increasing risk of NMBA-induced anaphylaxis considerably. However, other, still unknown factors occasionally might induce IgE-antibodies to SUX.
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Affiliation(s)
| | - Motohiro Kurosawa
- Gunma Institute for Allergy and Asthma, Tatebayashi-Kosei Hospital, Tatebayashi 374-0055, Japan
| | - Hee-Bom Moon
- Department of Internal Medicine, Asan Medical Center, University of Ulsan Collage of Medicine, Seoul 138-736, Korea
| | - Magnus Borres
- Department of Women's and Children's Health, Uppsala University, Thermo Fisher Scientific, Uppsala 751 05, Sweden
| | - Erik Florvaag
- Laboratory of Clinical Biochemistry, Department of Occupational Medicine, Haukeland University Hospital, Bergen 0027, Norway. ; Department of Clinical Science, University of Bergen, Bergen N-5020, Norway
| | - Stig Gunnar Olof Johansson
- Department of Medicine, Clinical Immunology and Allergy Unit, Karolinska University Hospital, Stockholm SE-141 86, Sweden
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Esnault P, Prunet B, Lacroix G, D'Aranda E, Gaillard Y, Boret H. Instantaneous rigor after fatal pholcodine intoxication. Br J Clin Pharmacol 2014; 77:578-9. [PMID: 23772895 PMCID: PMC4371536 DOI: 10.1111/bcp.12183] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Accepted: 06/04/2013] [Indexed: 11/27/2022] Open
Affiliation(s)
| | | | | | | | - Yvan Gaillard
- Toxicological Analysis LaboratoryLa Voulte sur Rhône, France
| | - Henry Boret
- Military Teaching Hospital Sainte AnneToulon, France
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Rouzaire P, Nosbaum A, Mullet C, Diot N, Dubost R, Bienvenu F, Guilloux L, Piriou V, Bienvenu J, Bérard F. Reply: To PMID 24565485. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2013; 1:710-711. [PMID: 24565730 DOI: 10.1016/j.jaip.2013.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Accepted: 09/06/2013] [Indexed: 06/03/2023]
Affiliation(s)
- Paul Rouzaire
- Immunology Laboratory, CHU Lyon-Sud, Pierre Bénite Cedex, France; Inserm U851, Lyon, France; Lyon1 University, IFR128, Lyon, France.
| | - Audrey Nosbaum
- Inserm U851, Lyon, France; Lyon1 University, IFR128, Lyon, France; Department of Allergy and Clinical Immunology, CHU Lyon-Sud, Pierre Bénite Cedex, France
| | | | - Nathalie Diot
- Department of Anesthesia, CHU Lyon, Pierre Bénite Cedex, France
| | - Rolande Dubost
- Department of Anesthesia, CHU Lyon, Pierre Bénite Cedex, France
| | | | | | - Vincent Piriou
- Department of Anesthesia, CHU Lyon, Pierre Bénite Cedex, France
| | - Jacques Bienvenu
- Immunology Laboratory, CHU Lyon-Sud, Pierre Bénite Cedex, France; Inserm U851, Lyon, France; Lyon1 University, IFR128, Lyon, France
| | - Frédéric Bérard
- Inserm U851, Lyon, France; Lyon1 University, IFR128, Lyon, France; Department of Allergy and Clinical Immunology, CHU Lyon-Sud, Pierre Bénite Cedex, France
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Adriaensens I, Vercauteren M, Soetens F, Janssen L, Leysen J, Ebo D. Allergic reactions during labour analgesia and caesarean section anaesthesia. Int J Obstet Anesth 2013; 22:231-42. [DOI: 10.1016/j.ijoa.2013.04.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Revised: 04/10/2013] [Accepted: 04/14/2013] [Indexed: 01/09/2023]
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Immediate Allergic Hypersensitivity to Quinolones Associates with Neuromuscular Blocking Agent Sensitization. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2013; 1:273-9.e1. [DOI: 10.1016/j.jaip.2013.02.007] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Revised: 02/13/2013] [Accepted: 02/19/2013] [Indexed: 11/17/2022]
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Sadleir PHM, Clarke RC, Bunning DL, Platt PR. Anaphylaxis to neuromuscular blocking drugs: incidence and cross-reactivity in Western Australia from 2002 to 2011. Br J Anaesth 2013; 110:981-7. [PMID: 23335568 DOI: 10.1093/bja/aes506] [Citation(s) in RCA: 101] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Neuromuscular blocking drugs (NMBDs) are the most common cause of intraoperative anaphylaxis in Western Australia. Differences in the rates of anaphylaxis between individual agents have been surmised in the past, but not proven, and are an important consideration if agents are otherwise equivalent. METHODS We estimated a rate of anaphylaxis to NMBDs by analysing cases of NMBD anaphylaxis referred to the only specialized diagnostic centre in Western Australia over a 10 yr period. Exposure was approximated by analysing a 5 yr period of NMBD ampoule sales data. Agents were also ranked according to the prevalence of cross-reactivity in patients with previous NMBD anaphylaxis. RESULTS Rocuronium was responsible for 56% of cases of NMBD anaphylaxis, succinylcholine 21%, and vecuronium 11%. There was no difference in the severity of reactions for different NMBDs. Rocuronium had a higher rate of IgE-mediated anaphylaxis compared with vecuronium (8.0 vs 2.8 per 100,000 exposures; P=0.0013). The prevalence of cross-reactivity after NMBD anaphylaxis suggested that succinylcholine also has a high risk of triggering anaphylaxis. Cisatracurium had the lowest prevalence of cross-reactivity in patients with known anaphylaxis to rocuronium or vecuronium. CONCLUSIONS Rocuronium has a higher rate of IgE-mediated anaphylaxis compared with vecuronium, a result that is statistically significant and clinically important. Cisatracurium had the lowest rate of cross-reactivity in patients who had previously suffered anaphylaxis to rocuronium or vecuronium.
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Affiliation(s)
- P H M Sadleir
- Sir Charles Gairdner Hospital, Perth, Western Australia.
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Anaphylaxis associated with general anaesthesia: Challenges and recent advances. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2012. [DOI: 10.1016/j.tacc.2012.08.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Florvaag E, Johansson SGO. The Pholcodine Case. Cough Medicines, IgE-Sensitization, and Anaphylaxis: A Devious Connection. World Allergy Organ J 2012; 5:73-8. [PMID: 23283141 PMCID: PMC3651177 DOI: 10.1097/wox.0b013e318261eccc] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
: The Scandinavian data on pholcodine (PHO) strongly indicates that there is a biological chain from PHO exposure through IgE-sensitization to IgE-mediated anaphylaxis to neuromuscular blocking agents (NMBA). PHO is probably one of the strongest inducer of an IgE antibody response known. Of individuals taking PHO in cough medicines, over-the-counter accessibility to large populations, as many as 20 to 25% may become IgE sensitized. Once sensitized, PHO re-exposure will booster IgE antibody levels and IgE by around 100-fold. PHO is monovalent for 2 non-cross-reacting epitopes the quaternary ammonium ion (QAI), the main allergenic epitope of NMBA, and a non-QAI epitope. Thus, PHO most unlikely would initiate an allergic inflammatory response. Consequently, IgE sensitization is not revealed by obvious clinical signs, neither through tests based on IgE-sensitized effector cells. Therefore, it will escape detection if not assayed serologically. However, when subjected to general anesthesia, and thus the IgE-sensitized individual is administered a bivalent NMBA intravenously, the unrecognized presence of serum IgE antibodies to QAI may increase the risk of anaphylaxis 200- to 300-fold. Severe damages to patient's health can result, and mortality rates of 3 to 10% are reported. The Scandinavian experience indicates that the chain of events can efficiently be avoided by stopping PHO exposure: Within 1 year, the prevalence of IgE sensitization to PHO and QAI decreases significantly, and after 2 to 3 years, the numbers of reported anaphylactic reactions decreases equally so.
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Affiliation(s)
- E Florvaag
- Laboratory of Clinical Biochemistry and Section for Clinical Allergology, Department of Occupational Medicine, Haukeland University Hospital, Bergen, Norway
- Institute of Medicine, University of Bergen, Norway
| | - SGO Johansson
- Clinical Immunology and Allergy Unit, Department of Medicine, Karolinska Institute, Stockholm, Sweden
- Department of Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden
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Hagau N, Gherman-Ionica N, Hagau D, Tranca S, Sfichi M, Longrois D. Is a positive history of non-anaesthetic drug allergy a predictive factor for positive allergy tests to anaesthetics? Br J Clin Pharmacol 2012; 73:460-6. [PMID: 21988224 DOI: 10.1111/j.1365-2125.2011.04112.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
AIMS International recommendations stipulate not performing screening skin tests to a drug in the absence of a clinical history consistent with that specific drug allergy. Nevertheless, two publications showed that a positive history of non-anaesthetic drug allergy was the only predictive factor for a positive skin test when screening for allergy to anaesthetic drugs was done. We selected from a surgical population 40 volunteers with a prior history of allergy to non-anaesthetic drugs in order to analyse the prevalence of positive allergy tests to anaesthetics. METHODS The selected adult patients were tested for 11 anaesthetic drugs using in vivo tests: skin prick (SPT) and intradermal (IDT) tests and in vitro tests: the basophil activation test (BAT) and detection of drug-specific immunoglobulin E (IgE). RESULTS The prevalence for the positive SPT and IDT was 1.6% and 5.8% respectively. The result of flow cytometry agreed with the SPT in five out of seven positive SPT (71%). IgEs confirmed two positive SPT with corresponding positive BAT. Ten per cent of the patients had a positive prick test to neuromuscular blocking agents (NMBA). For midazolam none of the SPT was positive, but 11 patients had positive IDT nonconfirmed by BAT. CONCLUSION The prevalence of positive in vivo and in vitro allergy tests to NMBAs is higher in our study population. This could be an argument for pre-operative SPT to NMBAs for the surgical population with reported non-anaesthetic drug allergies. A larger prospective study is needed to validate changes in clinical practice.
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Affiliation(s)
- Natalia Hagau
- Department of Anaesthesia and Intensive Care, University of Medicine and Pharmacy 'Iuliu Hatieganu' Cluj-Napoca, Romania.
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Gurrieri C, Weingarten TN, Martin DP, Babovic N, Narr BJ, Sprung J, Volcheck GW. Allergic Reactions During Anesthesia at a Large United States Referral Center. Anesth Analg 2011; 113:1202-12. [DOI: 10.1213/ane.0b013e31822d45ac] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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