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van der Poorten MLM, Vlaeminck N, Van Pée J, Thiele N, Smout K, Elst J, Toscano A, Van Gasse AL, Hagendorens MM, Aerts S, Adriaensens I, Sermeus LA, Garvey LH, Sabato V, Ebo DG. Drug provocation tests with hypnotics, opioids, and neuromuscular blocking agents in the diagnosis of suspected perioperative hypersensitivity. Br J Anaesth 2022; 129:e119-e122. [DOI: 10.1016/j.bja.2022.07.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 07/26/2022] [Indexed: 11/16/2022] Open
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2
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Dyess NF, Albertz ML, Murphy ME, Kinsella JP. Severe Bronchoconstriction Caused by Administration of Rocuronium in a 3-Month-Old Infant: Case Report. J Pediatr 2021; 228:297-300. [PMID: 32798566 DOI: 10.1016/j.jpeds.2020.08.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 08/06/2020] [Accepted: 08/12/2020] [Indexed: 11/16/2022]
Abstract
We present the case of a 3-month-old infant with severe, persistent bronchoconstriction following administration of rocuronium. This observation raises awareness of a rare but potentially life-threatening reaction to neuromuscular blocking agents.
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Affiliation(s)
- Nicolle F Dyess
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO.
| | - Megan L Albertz
- Section of Anesthesiology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Michael E Murphy
- Department of Pharmacy, Children's Hospital Colorado, Aurora, CO
| | - John P Kinsella
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
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Ma M, Zhu B, Zhao J, Li H, Zhou L, Wang M, Zhang X, Huang Y. Pediatric Patients with Previous Anaphylactic Reactions to General Anesthesia: a Review of Literature, Case Report, and Anesthetic Considerations. Curr Allergy Asthma Rep 2020; 20:15. [PMID: 32323069 DOI: 10.1007/s11882-020-00911-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
PURPOSE OF REVIEW It is rare to see pediatric patients with previous perioperative anaphylaxis receiving future anesthesia, but it is critical to understand how to choose assessments, interpret the results, and develop a future anesthetic plan. RECENT FINDINGS Analysis of the results revealed that patients, at any age, regardless of sex and nationality, and the number of surgeries, have the risk of perioperative anaphylaxis while the risk of allergy increases as patients present multiple surgical events or have a previous history of atopy. 94.7% of pediatric patients with allergy testing after perioperative anaphylaxis tolerated subsequent general anesthesia without complications. Specific IgE tests, basophil activation tests, and skin tests are not available and suitable for all culprits. The early skin test could be considered a supplement for later testing. Drug challenge test is the golden standard but can only be used as the last resort. If general anesthesia is inevitable, avoidance of the culprit and use of alternative agents can help the patients prevent another potential recurrence. Full use of inhalation anesthesia without unnecessary neuromuscular blockade agents and avoidance of latex is recommended when the surgery is urgent or skin tests for children cannot be performed in time. This review summarizes characteristics of perioperative pediatric anaphylaxis, main tests for various drugs, and their sensitivities and specificities as well as recommendations as to how to implement safe anesthesia in the future.
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Affiliation(s)
- Manjiao Ma
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No.1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Bo Zhu
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No.1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China.
| | - Jing Zhao
- Department of Anesthesiology, China-Japan Friendship Hospital, Beijing, China
| | - Hongyi Li
- Department of Anesthesiology, Cancer Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Lian Zhou
- Department of Stomatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Mu Wang
- Department of Stomatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xiuhua Zhang
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No.1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Yuguang Huang
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No.1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
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Skin Testing to Identify Safe Drugs for Patients with Rocuronium-Induced Anaphylaxis. Case Rep Anesthesiol 2020; 2020:8163620. [PMID: 32082637 PMCID: PMC7008275 DOI: 10.1155/2020/8163620] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 12/30/2019] [Indexed: 01/14/2023] Open
Abstract
Among patients who develop anaphylaxis during anesthesia, anaphylaxis caused by a neuromuscular blocking agent has the highest incidence. In patients who developed IgE-mediated anaphylaxis, and cross-reactivity among NMBAs is a concern in subsequent anesthetic procedures. We present a patient who developed rocuronium-induced anaphylaxis in whom the skin prick test (SPT) and intradermal test (IDT) could identify a safe drug to use in the subsequent anesthetic procedure. A 32-year-old female developed anaphylactic shock at the induction of general anesthesia. She recovered by administration of hydrocortisone and epinephrine. Skin tests including the SPT followed by the IDT revealed rocuronium as the drug that caused anaphylaxis and vecuronium as a safe drug to use for the subsequent general anesthesia. She safely underwent surgery with general anesthesia using vecuronium one month after the skin testing. There are not many reports on the effectiveness of the SPT followed by IDT in identifying the causative drug as well as a safe drug to use in the subsequent anesthetic procedure following anaphylaxis during anesthesia. The usefulness of the SPT should be re-evaluated.
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Sabato V, Ebo DG. Hypersensitivity to Neuromuscular Blocking Agents: Can Skin Tests Give the Green Light for Re-Exposure? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 6:1690-1691. [PMID: 30197072 DOI: 10.1016/j.jaip.2018.02.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 02/10/2018] [Indexed: 11/26/2022]
Affiliation(s)
- Vito Sabato
- Department of Immunology, Allergology, Rheumatology, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium; Department of Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium
| | - Didier G Ebo
- Department of Immunology, Allergology, Rheumatology, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium; Department of Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium.
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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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Hopkins P, Cooke P, Clarke R, Guttormsen A, Platt P, Dewachter P, Ebo D, Garcez T, Garvey L, Hepner D, Khan D, Kolawole H, Kopac P, Krøigaard M, Laguna J, Marshall S, Mertes P, Rose M, Sabato V, Savic L, Savic S, Takazawa T, Volcheck G, Voltolini S, Sadleir P. Consensus clinical scoring for suspected perioperative immediate hypersensitivity reactions. Br J Anaesth 2019; 123:e29-e37. [DOI: 10.1016/j.bja.2019.02.029] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 02/26/2019] [Accepted: 02/28/2019] [Indexed: 12/27/2022] Open
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Garvey LH, Ebo DG, Krøigaard M, Savic S, Clarke R, Cooke P, Dewachter P, Garcez T, Guttormsen AB, Hopkins PM, Hepner DL, Khan DA, Kolawole H, Kopac P, Marshall S, Mertes PM, Platt P, Rose M, Sabato V, Sadleir P, Savic L, Scherer K, Takazawa T, Volcheck GW, Voltolini S, Laguna JJ. The use of drug provocation testing in the investigation of suspected immediate perioperative allergic reactions: current status. Br J Anaesth 2019; 123:e126-e134. [DOI: 10.1016/j.bja.2019.03.018] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 03/09/2019] [Accepted: 03/12/2019] [Indexed: 01/23/2023] Open
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Li J, Best OG, Rose MA, Green SL, Fulton RB, Capon MJ, Krupowicz BA, Fernando SL. Assessing cross-reactivity to neuromuscular blocking agents by skin and basophil activation tests in patients with neuromuscular blocking agent anaphylaxis. Br J Anaesth 2019; 123:e144-e150. [PMID: 30961915 DOI: 10.1016/j.bja.2019.03.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 02/20/2019] [Accepted: 03/01/2019] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Following diagnosis of neuromuscular blocking agent (NMBA) anaphylaxis, identifying safe alternatives for subsequent anaesthesia is critical. A patient with anaphylaxis to one NMBA can also have an allergic reaction to other NMBAs (cross-reactivity). Whilst drug provocation testing is standard for identifying or excluding allergy, there is significant risk. In vitro, after an allergen activates basophils, basophils express surface activation markers that can be measured by basophil activation testing (BAT). We compared cross-reactivity between NMBAs assessed by BAT against that by skin testing. METHODS All patients attending an anaesthetic allergy clinic in Sydney, Australia between May 2017 and July 2018 diagnosed with NMBA anaphylaxis qualified for this study comparing intradermal skin tests and BAT with a panel of NMBAs (rocuronium, vecuronium, pancuronium, suxamethonium, cisatracurium). RESULTS Of the 61 patients participating, sensitisation on skin testing and on BAT completely matched in only nine patients (15%). Sensitisation was not in agreement for pancuronium, cisatracurium and rocuronium, but was in agreement for vecuronium and suxamethonium. Nine patients with negative skin tests subsequently tolerated cisatracurium, and one false positive on BAT to cisatracurium was detected. CONCLUSIONS The utility of BAT in identifying safe NMBAs for subsequent anaesthesia needs further evaluation. BAT detects a different cross-reactivity profile to skin tests. Negative skin testing and BAT might increase confidence in performing drug provocation testing, but this and follow-up of subsequent anaesthesia in our cohort is necessary to determine the clinical significance of BAT sensitisation.
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Affiliation(s)
- Jamma Li
- Department of Clinical Immunology and Allergy, Australia; Medicine (Immunology & Infectious Diseases), University of Sydney, Sydney, Australia; NSW Health Pathology, Sydney, Australia.
| | - Oliver G Best
- Medicine (Immunology & Infectious Diseases), University of Sydney, Sydney, Australia
| | - Michael A Rose
- Department of Anaesthesia, Royal North Shore Hospital, Sydney, Australia
| | - Sarah L Green
- Department of Anaesthesia, Royal North Shore Hospital, Sydney, Australia
| | | | - Marc J Capon
- Department of Anaesthesia, Royal North Shore Hospital, Sydney, Australia
| | | | - Suran L Fernando
- Department of Clinical Immunology and Allergy, Australia; Medicine (Immunology & Infectious Diseases), University of Sydney, Sydney, Australia; NSW Health Pathology, Sydney, Australia
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Anaesthetic management of patients with pre-existing allergic conditions: a narrative review. Br J Anaesth 2019; 123:e65-e81. [PMID: 30916009 DOI: 10.1016/j.bja.2019.01.020] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 01/12/2019] [Accepted: 01/22/2019] [Indexed: 12/18/2022] Open
Abstract
This narrative review seeks to distinguish the clinical patterns of pre-existing allergic conditions from other confounding non-allergic clinical entities, and to identify the potential related risks and facilitate their perioperative management. Follow-up investigation should be performed after a perioperative immediate hypersensitivity to establish a diagnosis and provide advice for subsequent anaesthetics, the main risk factor for perioperative immunoglobulin E (IgE)-mediated anaphylaxis being a previous uninvestigated perioperative immediate hypersensitivity reaction. The concept of cross-reactivity between drugs used in the perioperative setting and food is often quoted, but usually not supported by evidence. There is no reason to avoid propofol in egg, soy, or peanut allergy. The allergenic determinants have been characterised for fish, shellfish, and povidone iodine, but remain unknown for iodinated contrast agents. Iodinated drugs may be used in seafood allergy. Evidence supporting the risk for protamine allergy in fish allergy and in neutral protamine Hagedorn insulin use is lacking. Conversely, cross-reactivity to gelatin-based colloid may occur in α-gal syndrome. Atopy and allergic asthma along with other non-allergic conditions, such as NSAID-exacerbated respiratory disease, chronic urticaria, mastocytosis, and hereditary or acquired angioedema, are not risk factors for IgE-mediated drug allergy, but there is a perioperative risk associated with the potential for exacerbation of the various conditions.
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11
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De La Cruz I, Errando C, Calaforra S. Treatment of Anaphylaxis to Rocuronium with Sugammadex: A Case Report with Bronchospasm as the Only Symptom. Turk J Anaesthesiol Reanim 2019; 47:69-72. [PMID: 31276114 DOI: 10.5152/tjar.2019.21298] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 09/27/2018] [Indexed: 12/26/2022] Open
Abstract
Anaphylaxis during anaesthesia is a rare event occurring in up to 1:20,000 anaesthetics and in 33%-63% neuromuscular blocking agents are involved. Several case reports suggested the effectiveness of sugammadex in the treatment of rocuronium-induced anaphylactic shock refractory to conventional treatment. We report a case of anaphylactic reaction to rocuronium that caused isolated respiratory symptoms and showed no improvement in oxygen saturation after intravenous corticosteroids and intratracheal beta-2 agonists and that was successfully treated with sugammadex. The underlying pathophysiological mechanisms that explain the potential beneficial effect of sugammadex in this context are not completely known. We briefly review the literature regarding this topic.
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Affiliation(s)
- Itziar De La Cruz
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University General Hospital, Valencia, Spain
| | - Carlos Errando
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University General Hospital, Valencia, Spain
| | - Susana Calaforra
- Department of Allergy and Clinical Immunology, La Fe University and Polytechnic Hospital, Valencia, Spain
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12
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Petitpain N, Argoullon L, Masmoudi K, Fedrizzi S, Cottin J, Latarche C, Mertes PM, Gillet P. Neuromuscular blocking agents induced anaphylaxis: Results and trends of a French pharmacovigilance survey from 2000 to 2012. Allergy 2018; 73:2224-2233. [PMID: 29654608 DOI: 10.1111/all.13456] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Perioperative anaphylaxis mainly involves neuromuscular blocking agents (NMBAs) with an IgE-mediated mechanism. In France, this life-threatening condition is reported by anesthetists and allergologists, and two safety alerts concerning suxamethonium were raised in 2011 and 2012. This led to start a national survey over the 2000-2012 period which objectives were to provide a descriptive analysis, to estimate incidence rates, and to analyze the trends over this period. METHODS The French pharmacovigilance database was retrospectively queried for all the available NMBAs. Anaphylaxis cases with elevated tryptase and positive skin tests were qualified as "confirmed cases." Subgroup analysis compared atracurium and cisatracurium vs suxamethonium and rocuronium. RESULTS A total of 680 confirmed cases and 944 nonconfirmed cases were identified. Suxamethonium was the most implied NMBA (64%). Incidence rates (according to sales data) of suxamethonium and rocuronium were, respectively, 10- and 13-folds higher than those of the others NMBAs, regardless the confirmed/nonconfirmed status. Cisatracurium incidence rates remained stable over the period, while suxamethonium and atracurium increased and rocuronium first decreased but re-increased after 2006. Male patients were more frequent in the subgroup "atracurium-cisatracurium" (P = .019), whereas obesity and emergency setting were more frequent in the subgroup "rocuronium-suxamethonium." Shared characteristics were the poorly documented previous exposure to NMBA(s) and an insufficient adherence of patients to perform skin tests, showing the need to improve this procedure. CONCLUSION Suxamethonium and rocuronium are markedly more involved in perioperative anaphylaxis than the other available NMBAs. Patients should be more informed about their perioperative anaphylaxis and its consequences.
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Affiliation(s)
- N. Petitpain
- Regional Pharmacovigilance Centre of Nancy; University Hospital of Nancy; Nancy France
| | - L. Argoullon
- Regional Pharmacovigilance Centre of Nancy; University Hospital of Nancy; Nancy France
| | - K. Masmoudi
- Department of Clinical Pharmacology; Regional Pharmacovigilance Centre of Amiens; University Hospital of Amiens; Amiens France
| | - S. Fedrizzi
- Regional Pharmacovigilance Center of Caen; University Hospital of Caen; Caen France
| | - J. Cottin
- Regional Pharmacovigilance Centre of Lyon; University Hospital of Lyon; Lyon France
| | - C. Latarche
- Department of Epidemiology; University Hospital of Nancy; Nancy France
| | - P. M. Mertes
- Department of Anesthesia; CHRU of Strasbourg; Nouvel Hôpital Civil; Strasbourg France
| | - P. Gillet
- Department of Clinical Pharmacology; University Hospital of Nancy; Nancy France
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13
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Dewachter P, Chollet-Martin S, Mouton-Faivre C, de Chaisemartin L, Nicaise-Roland P. Comparison of Basophil Activation Test and Skin Testing Performances in NMBA Allergy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:1681-1689. [DOI: 10.1016/j.jaip.2017.12.037] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Revised: 11/28/2017] [Accepted: 12/27/2017] [Indexed: 12/31/2022]
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Chiriac A, Tacquard C, Fadhel N, Pellerin C, Malinovsky J, Mertes P, Demoly P. Safety of subsequent general anaesthesia in patients allergic to neuromuscular blocking agents: value of allergy skin testing. Br J Anaesth 2018; 120:1437-1440. [DOI: 10.1016/j.bja.2018.03.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 02/21/2018] [Accepted: 03/08/2018] [Indexed: 11/28/2022] Open
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Reclassifying Anaphylaxis to Neuromuscular Blocking Agents Based on the Presumed Patho-Mechanism: IgE-Mediated, Pharmacological Adverse Reaction or "Innate Hypersensitivity"? Int J Mol Sci 2017; 18:ijms18061223. [PMID: 28590439 PMCID: PMC5486046 DOI: 10.3390/ijms18061223] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 06/01/2017] [Accepted: 06/02/2017] [Indexed: 01/18/2023] Open
Abstract
Approximately 60% of perioperative anaphylactic reactions are thought to be immunoglobulin IgE mediated, whereas 40% are thought to be non-IgE mediated hypersensitivity reactions (both considered non-dose-related type B adverse drug reactions). In both cases, symptoms are elicited by mast cell degranulation. Also, pharmacological reactions to drugs (type A, dose-related) may sometimes mimic symptoms triggered by mast cell degranulation. In case of hypotension, bronchospasm, or urticarial rash due to mast cell degranulation, identification of the responsible mechanism is complicated. However, determination of the type of the underlying adverse drug reaction is of paramount interest for the decision of whether the culprit drug may be re-administered. Neuromuscular blocking agents (NMBA) are among the most frequent cause of perioperative anaphylaxis. Recently, it has been shown that NMBA may activate mast cells independently from IgE antibodies via the human Mas-related G-protein-coupled receptor member X2 (MRGPRX2). In light of this new insight into the patho-mechanism of pseudo-allergic adverse drug reactions, in which as drug-receptor interaction results in anaphylaxis like symptoms, we critically reviewed the literature on NMBA-induced perioperative anaphylaxis. We challenge the dogma that NMBA mainly cause IgE-mediated anaphylaxis via an IgE-mediated mechanism, which is based on studies that consider positive skin test to be specific for IgE-mediated hypersensitivity. Finally, we discuss the question whether MRGPRX2 mediated pseudo-allergic reactions should be re-classified as type A adverse reactions.
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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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17
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Chiriac AM, Demoly P. [Allergy to neuromuscular blocking agents]. Presse Med 2016; 45:768-73. [PMID: 27234905 DOI: 10.1016/j.lpm.2016.02.023] [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] [Received: 02/01/2016] [Accepted: 02/23/2016] [Indexed: 11/26/2022] Open
Abstract
Allergy to neuromuscular blocking agents (NMBAs) has been the first cause of perioperative anaphylaxis for decades, in most countries. The most frequently involved agents are suxamethonium and rocuronium. The allergy work-up is compulsory to demonstrate or rule out allergy to NMBAs, if there is a compatible clinical history. Doing otherwise exposes the patient to death if the same or related NMBA is re-injected. In cases of true allergy, assessing cross-reactivity to other NMBAs is mandatory. The cross-sensitization hypothesis is presently being investigated and if confirmed, it could allow primary prevention measures to be implemented.
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Affiliation(s)
- Anca-Mirela Chiriac
- Centre hospitalier universitaire de Montpellier, hôpital Arnaud-de-Villeneuve, département de pneumologie et addictologie, unité exploration des allergies, 34295 Montpellier, France; Sorbonne universités, UPMC Paris 06, UMR_S 1136, institut Pierre-Louis d'épidémiologie et de santé publique, équipe EPAR, 75013 Paris, France.
| | - Pascal Demoly
- Centre hospitalier universitaire de Montpellier, hôpital Arnaud-de-Villeneuve, département de pneumologie et addictologie, unité exploration des allergies, 34295 Montpellier, France; Sorbonne universités, UPMC Paris 06, UMR_S 1136, institut Pierre-Louis d'épidémiologie et de santé publique, équipe EPAR, 75013 Paris, 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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Leysen J, Uyttebroek A, Sabato V, Bridts CH, De Clerck LS, Ebo DG. Predictive value of allergy tests for neuromuscular blocking agents: tackling an unmet need. Clin Exp Allergy 2015; 44:1069-75. [PMID: 24848972 DOI: 10.1111/cea.12344] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Revised: 05/08/2014] [Accepted: 05/13/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Neuromuscular blocking agents (NMBAs) are a predominant cause of perioperative anaphylaxis in Europe. Diagnosis of NMBA allergy relies upon the careful review of the anaesthetic report complemented with skin tests. Additional diagnostic tests are quantification of specific IgE antibodies (sIgE) and basophil activation test (BAT). However, data on the predictive value of the skin tests, the BAT and the sIgE assays (drug-specific and substituted ammonium structures) are limited or not available, mainly because such exploration requires dangerous NMBA provocation tests. METHODS In this study, the predictive value of skin test, BAT and measurement of sIgE to substituted ammonium structures is gathered from a review of anaesthetic records of subsequent surgical procedures with NMBA administration and/or occurrence of perioperative incidents. RESULTS We investigated a series of 272 patients with perioperative anaphylaxis, of whom 100 had undergone second general anaesthesia. Negative skin test and negative BAT assisted the selection of alternative NMBA, which were well tolerated in all cases. Five patients with a positive sIgE to rocuronium but with negative skin testing and BAT safely received rocuronium during second anaesthesia. Twelve patients with sIgE reactivity to morphine, but negative skin test and BAT to benzylisoquinolines, tolerated administration of cisatracurium or atracurium. Alternatively, benzylisoquinoline allergy went undetected in the morphine solid-phase assay. CONCLUSIONS Skin test and BAT have an excellent negative predictive value in our series. The uneventful re-exposure of rocuronium in patients with an isolated positive sIgE result to rocuronium calls into question the predictive value of this assay and suggests sIgE serology to be less clinically predictive than the functional investigations relying upon activation of mast cells or basophils. The presence of a positive sIgE to substituted ammonium structures such as morphine does not preclude further use of benzylisoquinolines.
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Affiliation(s)
- J Leysen
- Faculty of Medicine and Health Science, Department of Immunology - Allergology - Rheumatology, University of Antwerp, Antwerp University Hospital, Antwerpen, Belgium
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Gouel-Chéron A, Neukirch C, Aubier B, Montravers P, Nicaise P, Chollet-Martin S, Mertes PM, Aubier M, Longrois D. Anaphylactic bronchospasm during general anesthesia is not related to asthma. Allergy 2015; 70:453-6. [PMID: 25556961 DOI: 10.1111/all.12565] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2014] [Indexed: 10/24/2022]
Abstract
In the general population, a history of asthma (HA) is associated with a higher risk of mortality of anaphylactic shock (AS), but it is unknown whether this association remains valid for intra-operative AS. The goal of this retrospective study was to investigate whether a HA was associated with a higher risk of bronchospasm during intra-operative AS. We analyzed 106 patients (January 2009-December 2012) with intra-operative AS: 57% of them had a confirmed IgE-mediated reaction and 27% had a HA. On logistic regression, the only factor statistically associated with bronchospasm was a neuromuscular blocking drug, with both IgE- or non-IgE-mediated reactions. These results suggest that the mechanisms of bronchospasm in AS may be different from those of asthma and that, in the presence of bronchospasm during anesthesia, AS should be considered to be the most likely cause.
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Affiliation(s)
- A. Gouel-Chéron
- Département d'Anesthésie-Réanimation; Hôpital Bichat-Claude Bernard; Paris France
| | - C. Neukirch
- Service de Pneumologie; Hôpital Bichat-Claude Bernard; Paris France
| | - B. Aubier
- Département d'Anesthésie-Réanimation; Hôpital Bichat-Claude Bernard; Paris France
| | - P. Montravers
- Département d'Anesthésie-Réanimation; Hôpital Bichat-Claude Bernard; Paris France
| | - P. Nicaise
- Laboratoire d'Immunologie “Auto-Immunité et Hypersensibilités”; Hôpital Bichat-Claude Bernard; Paris France
| | - S. Chollet-Martin
- Laboratoire d'Immunologie “Auto-Immunité et Hypersensibilités”; Hôpital Bichat-Claude Bernard; Paris France
| | - P.-M. Mertes
- Service d'Anesthésie-Réanimation; Nouvel Hôpital Civil, CHU de Strasbourg; Strasbourg France
| | - M. Aubier
- Service de Pneumologie; Hôpital Bichat-Claude Bernard; Paris France
| | - D. Longrois
- Département d'Anesthésie-Réanimation; Hôpital Bichat-Claude Bernard; Paris France
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Simons FER, Ardusso LRF, Dimov V, Ebisawa M, El-Gamal YM, Lockey RF, Sanchez-Borges M, Senna GE, Sheikh A, Thong BY, Worm M. World Allergy Organization Anaphylaxis Guidelines: 2013 update of the evidence base. Int Arch Allergy Immunol 2013; 162:193-204. [PMID: 24008815 DOI: 10.1159/000354543] [Citation(s) in RCA: 144] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The World Allergy Organization (WAO) Guidelines for the assessment and management of anaphylaxis are a widely disseminated and used resource for information about anaphylaxis. They focus on patients at risk, triggers, clinical diagnosis, treatment in health care settings, self-treatment in the community, and prevention of recurrences. Their unique strengths include a global perspective informed by prior research on the global availability of essentials for anaphylaxis assessment and management and a global agenda for anaphylaxis research. Additionally, detailed colored illustrations are linked to key concepts in the text [Simons et al.: J Allergy Clin Immunol 2011;127:593.e1-e22]. The recommendations in the original WAO Anaphylaxis Guidelines for management of anaphylaxis in health care settings and community settings were based on evidence published in peer-reviewed, indexed medical journals to the end of 2010. These recommendations remain unchanged and clinically relevant. An update of the evidence base was published in 2012 [Simons et al.: Curr Opin Allergy Clin Immunol 2012;12:389-399]. In 2012 and early 2013, major advances were reported in the following areas: further characterization of patient phenotypes; development of in vitro tests (for some allergens) that help distinguish clinical risk of anaphylaxis from asymptomatic sensitization; epinephrine (adrenaline) research, including studies of a new epinephrine auto-injector for use in community settings, and randomized controlled trials of immunotherapy to prevent food-induced anaphylaxis. Despite these advances, the need for additional prospective studies, including randomized controlled trials of interventions in anaphylaxis is increasingly apparent. This 2013 Update highlights publications from 2012 and 2013 that further contribute to the evidence base for the recommendations made in the original WAO Anaphylaxis Guidelines. Ideally, it should be used in conjunction with these Guidelines and with the 2012 Guidelines Update.
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Affiliation(s)
- F Estelle R Simons
- Departments of Pediatrics and Child Health, and Immunology, Faculty of Medicine, University of Manitoba, Winnipeg, Man., Canada
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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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Hypersensitivity reactions in the anesthesia setting/allergic reactions to anesthetics. Curr Opin Allergy Clin Immunol 2012; 12:361-8. [DOI: 10.1097/aci.0b013e328355b82f] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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