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Drugs and Vaccines Hypersensitivity in Children with Mastocytosis. J Clin Med 2022; 11:jcm11113153. [PMID: 35683540 PMCID: PMC9181546 DOI: 10.3390/jcm11113153] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 05/25/2022] [Accepted: 05/30/2022] [Indexed: 02/04/2023] Open
Abstract
Mastocytosis, a heterogeneous mastcell disease, include three different entities: cutaneous mastocytosis, systemic mastocytosis (SM) and mast-cell sarcoma. Tryptase levels can differentiate cutaneous mastocytosis from SM. In mastocytosis, quick onset drug hypersensitivity reactions (DHRs) that are facilitated by mastcell mediators, are investigated in adults. Due to the limited number of children with mastcell disease and increased serum tryptase levels, the role of drugs in this age group is less studied. In this review, we critically assessed relevant papers related with immediate DHRs in children with mastocytosis and discuss practical issues of the management. In childhood mastocytosis, anaphylaxis is frequently idiopathic, and elevated level of basal tryptase, and high burden of disease may increase the risk. Among drugs, antibiotics, NSAIDs and opioids can potentially induce anaphylaxis, anyway avoidance should be recommended only in case of previous reactions. Moreover, vaccinations are not contraindicated in patients with mastocytosis. The risk of severe systemic reactions after drugs intake seems to be extremely low and in general lower in children than in adults. Anyway, studies on this topic especially focusing on children, are missing to state final recommendations.
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Broyles AD, Banerji A, Barmettler S, Biggs CM, Blumenthal K, Brennan PJ, Breslow RG, Brockow K, Buchheit KM, Cahill KN, Cernadas J, Chiriac AM, Crestani E, Demoly P, Dewachter P, Dilley M, Farmer JR, Foer D, Fried AJ, Garon SL, Giannetti MP, Hepner DL, Hong DI, Hsu JT, Kothari PH, Kyin T, Lax T, Lee MJ, Lee-Sarwar K, Liu A, Logsdon S, Louisias M, MacGinnitie A, Maciag M, Minnicozzi S, Norton AE, Otani IM, Park M, Patil S, Phillips EJ, Picard M, Platt CD, Rachid R, Rodriguez T, Romano A, Stone CA, Torres MJ, Verdú M, Wang AL, Wickner P, Wolfson AR, Wong JT, Yee C, Zhou J, Castells M. Practical Guidance for the Evaluation and Management of Drug Hypersensitivity: Specific Drugs. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 8:S16-S116. [PMID: 33039007 DOI: 10.1016/j.jaip.2020.08.006] [Citation(s) in RCA: 89] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 08/10/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Ana Dioun Broyles
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Aleena Banerji
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Sara Barmettler
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Catherine M Biggs
- Department of Pediatrics, British Columbia Children's Hospital, University of British Columbia, Vancouver, Canada
| | - Kimberly Blumenthal
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Patrick J Brennan
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Rebecca G Breslow
- Division of Sports Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein, School of Medicine, Technical University of Munich, Munich, Germany
| | - Kathleen M Buchheit
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Katherine N Cahill
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Josefina Cernadas
- Allergology and Immunology Service, Centro Hospitalar Universitário de S.João Hospital, Porto, Portugal
| | - Anca Mirela Chiriac
- Division of Allergy, Department of Pulmonology, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, France
| | - Elena Crestani
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Pascal Demoly
- Division of Allergy, Department of Pulmonology, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, France
| | - Pascale Dewachter
- Department of Anesthesiology and Intensive Care Medicine, Groupe Hospitalier Paris-Seine-Saint-Denis, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Meredith Dilley
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Jocelyn R Farmer
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Dinah Foer
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Ari J Fried
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Sarah L Garon
- Associated Allergists and Asthma Specialists, Chicago, Ill
| | - Matthew P Giannetti
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - David L Hepner
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Mass
| | - David I Hong
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Joyce T Hsu
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Parul H Kothari
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Timothy Kyin
- Division of Asthma, Allergy & Immunology, University of Virginia, Charlottesville, Va
| | - Timothy Lax
- Division of Allergy and Inflammation, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Min Jung Lee
- Allergy and Immunology at Hoag Medical Group, Newport Beach, Calif
| | - Kathleen Lee-Sarwar
- Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Anne Liu
- Division of Allergy / Immunology, Stanford University School of Medicine, Palo Alto, Calif
| | - Stephanie Logsdon
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Margee Louisias
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Andrew MacGinnitie
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Michelle Maciag
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Samantha Minnicozzi
- Division of Allergy and Clinical Immunology, Respiratory Medicine, Department of Pediatrics, University of Virginia, Charlottesville, Va
| | - Allison E Norton
- Division of Allergy, Immunology and Pulmonology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tenn
| | - Iris M Otani
- Division of Pulmonary, Critical Care, Allergy, and Sleep, Department of Medicine, University of California, San Francisco Medical Center, San Francisco, Calif
| | - Miguel Park
- Division of Allergic Diseases, Mayo Clinic, Rochester, Minn
| | - Sarita Patil
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Elizabeth J Phillips
- Department of Medicine & Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tenn
| | - Matthieu Picard
- Division of Allergy and Clinical Immunology, Department of Medicine, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Québec, Canada
| | - Craig D Platt
- Division of Immunology, Boston Children's Hospital, Boston, Mass
| | - Rima Rachid
- Division of Immunology, Boston Children's Hospital, Boston, Mass
| | - Tito Rodriguez
- Drug Allergy Department, Al-Rashed Allergy Center, Sulaibikhat, Al-Kuwait, Kuwait
| | - Antonino Romano
- IRCCS Oasi Maria S.S., Troina, Italy & Fondazione Mediterranea G.B. Morgagni, Catania, Italy
| | - Cosby A Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Maria Jose Torres
- Allergy Unit and Research Group, Hospital Regional Universitario de Málaga, UMA-IBIMA-BIONAND, ARADyAL, Málaga, Spain
| | - Miriam Verdú
- Allergy Unit, Hospital Universitario de Ceuta, Ceuta, Spain
| | - Alberta L Wang
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Paige Wickner
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Anna R Wolfson
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Johnson T Wong
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Christina Yee
- Division of Immunology, Boston Children's Hospital, Boston, Mass
| | - Joseph Zhou
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Mariana Castells
- Drug hypersensitivity and Desensitization Center, Brigham and Women's Hospital, Boston, Mass
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De Souza RL, Short T, Warman GR, Maclennan N, Young Y. Anaphylaxis with Associated Fibrinolysis, Reversed with Tranexamic Acid and Demonstrated by Thrombelastography. Anaesth Intensive Care 2019; 32:580-7. [PMID: 15675222 DOI: 10.1177/0310057x0403200419] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In the surgical setting, fibrinolysis can be a serious complication of anaphylaxis. We present four cases of anaphylaxis that were associated with fibrinolysis during anaesthesia, and the use of the thrombelastograph to demonstrate this haemostatic defect and its correction using tranexamic acid.
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Affiliation(s)
- R L De Souza
- Anaesthetic Department, Auckland Hospital, Auckland, New Zealand
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Abstract
General anaesthesia for the patient with a history of anaesthesia-related anaphylaxis is challenging. Precautions against anaphylaxis and the use of skin test negative drugs can reduce but not eliminate the risk. In the majority of such cases, subsequent anaesthesia is uneventful. However, the absence of a clearly identified triggering agent increases the difficulties facing the anaesthetist. We present a case of anaphylaxis to cisatracurium following a negative skin test.
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Affiliation(s)
- B A Fraser
- Department of Anaesthesia and Pain Management, Alfred Hospital, Melbourne, Victoria
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Bonadonna P, Zanotti R, Varani AB, Pagani M. Mast Cell Diseases and Drug Hypersensitivity Reactions. CURRENT TREATMENT OPTIONS IN ALLERGY 2017. [DOI: 10.1007/s40521-017-0130-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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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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Abstract
The incidence of anaphylaxis during anesthesia has been reported to range from 1 in 4000 to 1 in 25,000. Anaphylaxis during anesthesia can present as cardiovascular collapse, airway obstruction, and/or skin manifestation. It can be difficult to differentiate between immune and nonimmune mast cell-mediated reactions and pharmacologic effects from the variety of medications administered during general anesthesia. In addition, cutaneous manifestations of anaphylaxis are less likely to be apparent when anaphylaxis occurs in this setting. The evaluation of IgE-mediated reactions to medications used during anesthesia can include skin testing to a variety of anesthetic agents. Specifically, thiopental allergy has been documented by skin tests. Neuromuscular blocking agents such as succinylcholine can cause nonimmunologic histamine release, but there have also been reports of IgE-mediated reactions in some patients. Reactions to opioid analgesics are usually caused by direct mast cell mediator release rather than IgE-dependent mechanisms. Antibiotics that are administered perioperatively can cause immunologic or nonimmunologic reactions. Protamine can cause severe systemic reactions through IgE-mediated or nonimmunologic mechanisms. Blood transfusions can elicit a variety of systemic reactions, some of which might be IgE-mediated or mediated through other immunologic mechanisms. The management of anaphylactic reactions that occur during general anesthesia is similar to the management of anaphylaxis in other situations.
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Affiliation(s)
- Shrikant Mali
- MDS Oral and Maxillofacial Surgery, Sr Lecturer, Department of Oral and Maxillofacial Surgery CSMSS Dental College, Aurangabad, India
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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: 10] [Impact Index Per Article: 1.0] [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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12
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Cook T, MacDougall-Davis S. Complications and failure of airway management. Br J Anaesth 2012; 109 Suppl 1:i68-i85. [DOI: 10.1093/bja/aes393] [Citation(s) in RCA: 269] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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Mertes PM, Demoly P, Malinovsky JM. Complications anaphylactiques et anaphylactoïdes de l’anesthésie générale. ACTA ACUST UNITED AC 2012. [DOI: 10.1016/s0246-0289(12)59003-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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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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Florvaag E, Johansson SGO. Pholcodine in cough medicines and IgE-sensitization in the EU: an urgent task. Allergy 2012; 67:581-2. [PMID: 22380984 DOI: 10.1111/j.1398-9995.2012.02803.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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von Ungern-Sternberg BS. [Muscle relaxants are obligatory for pediatric intubation: con]. Anaesthesist 2011; 60:476-8. [PMID: 21562898 DOI: 10.1007/s00101-011-1879-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Abstract
Peri-operative anaphylaxis is an important cause for mortality and morbidity associated with anaesthesia. The true incidence is unknown and is most likely under reported. Diagnosis can be difficult, particularly as a number of drugs are given simultaneously and any of these agents can potentially cause anaphylaxis. This review covers the clinical features, differential diagnosis and management of anaphylaxis associated with anaesthesia. The investigations to confirm the clinical suspicion of anaphylaxis and further tests to identify the likely drug(s) are examined. Finally the salient features of common and rare causes including non-drug substances are described.
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Affiliation(s)
- Linda Nel
- Department of Anaesthetics, Southampton University Hospitals NHS TrustTremona Road, Southampton, United Kingdom
| | - Efrem Eren
- Department of Immunology, Southampton University Hospitals NHS TrustTremona Road, Southampton, United Kingdom
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Longrois D, Lejus C, Constant I, Bruyère M, Mertes PM. [Treatment of hypersensitivity reactions and anaphylactic shock occurring during anaesthesia]. ACTA ACUST UNITED AC 2011; 30:312-22. [PMID: 21377314 DOI: 10.1016/j.annfar.2010.12.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- D Longrois
- Département d'anesthésie-réanimation, hôpital Bichat-Claude-Bernard, 46 rue Henri-Huchard, Paris cedex 18, France
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Howard JD, Moo V, Sivalingam P. Anaphylaxis and other Adverse Reactions to Blue Dyes: A Case Series. Anaesth Intensive Care 2011; 39:287-92. [DOI: 10.1177/0310057x1103900221] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We report three cases of anaphylaxis during anaesthesia confirmed on intradermal testing to be related to patent blue V dye (Guerbet – Chemical Abstract Service 3536-49-0). All three cases were associated with moderate to severe hypotension. Two cases had delayed onset, and two were associated with a rash. None of the cases were associated with bronchospasm. In all three patients the interference with pulse oximetry readings contributed to difficulties in management. We recommend the use of a test dose of blue dye prior to surgery, as suggested in the manufacturer's product information. We also recommend high vigilance for possible allergic reactions when patent blue dyes are used for sentinel lymph node mapping, because the presentations may be atypical and the reduced pulse oximetry readings may be a distraction.
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Affiliation(s)
- J. D. Howard
- Department of Anaesthesia, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - V. Moo
- Department of Anaesthesia, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - P. Sivalingam
- Department of Anaesthesia, Princess Alexandra Hospital, Brisbane, Queensland, Australia
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Mertes PM, Karila C, Demoly P, Auroy Y, Ponvert C, Lucas MM, Malinovsky JM. [What is the reality of anaphylactoid reactions during anaesthesia? Classification, prevalence, clinical features, drugs involved and morbidity and mortality]. ACTA ACUST UNITED AC 2011; 30:223-39. [PMID: 21353759 DOI: 10.1016/j.annfar.2011.01.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- P-M Mertes
- Service d'anesthésie-réanimation chirurgicale, hôpital Central, CHU de Nancy, 29 avenue de Lattre-de-Tassigny, Nancy cedex, France.
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Miraj A, Foaud A, Seth B. Cardiac arrest following an anaphylactic reaction to atracurium. BMJ Case Rep 2010; 2010:2010/nov04_1/bcr0120102658. [PMID: 22791846 DOI: 10.1136/bcr.01.2010.2658] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
This report describes a life-threatening anaphylactic reaction in a 58-year-old woman who was scheduled for subacromial decompression of right shoulder joint. She had a modified rapid sequence induction using fentanyl 100 µg, propofol 150 mg and suxamethonium 100 mg. Following induction her blood pressure and pulse were stable. On return of spontaneous ventilation, she had intravenous administration of 30 mg of atracurium. Soon after, she developed profound bradycardia followed by a cardiac arrest. Cardiopulmonary resuscitation (CPR) commenced with 100% oxygen and intravenous administration of atropine 3 mg and epinephrine 1 mg. After 1 min of CPR she had the return of spontaneous circulation with a blood pressure of 160/100 mm Hg. Her sedation was maintained using minimal isoflurane until the return of spontaneous ventilation to avoid awareness. Surgery was postponed. Later she made an uneventful recovery. Her serum tryptase level was raised and a positive intradermal reaction to atracurium confirmed atracurium anaphylaxis.
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Affiliation(s)
- Adilah Miraj
- Department of Anaesthesia, Hinchingbrooke Hospital, Huntingdon, Cambridgeshire, UK.
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Lieberman P, Nicklas RA, Oppenheimer J, Kemp SF, Lang DM, Bernstein DI, Bernstein JA, Burks AW, Feldweg AM, Fink JN, Greenberger PA, Golden DBK, James JM, Kemp SF, Ledford DK, Lieberman P, Sheffer AL, Bernstein DI, Blessing-Moore J, Cox L, Khan DA, Lang D, Nicklas RA, Oppenheimer J, Portnoy JM, Randolph C, Schuller DE, Spector SL, Tilles S, Wallace D. The diagnosis and management of anaphylaxis practice parameter: 2010 update. J Allergy Clin Immunol 2010; 126:477-80.e1-42. [PMID: 20692689 DOI: 10.1016/j.jaci.2010.06.022] [Citation(s) in RCA: 460] [Impact Index Per Article: 32.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2009] [Revised: 04/27/2010] [Accepted: 06/08/2010] [Indexed: 11/19/2022]
Abstract
These parameters were developed by the Joint Task Force on Practice Parameters, representing the American Academy of Allergy, Asthma & Immunology (AAAAI); the American College of Allergy, Asthma & Immunology (ACAAI); and the Joint Council of Allergy, Asthma and Immunology. The AAAAI and the ACAAI have jointly accepted responsibility for establishing "The Diagnosis and Management of Anaphylaxis Practice Parameter: 2010 Update." This is a complete and comprehensive document at the current time. The medical environment is a changing environment, and not all recommendations will be appropriate for all patients. Because this document incorporated the efforts of many participants, no single individual, including those who served on the Joint Task Force, is authorized to provide an official AAAAI or ACAAI interpretation of these practice parameters. Any request for information about or an interpretation of these practice parameters by the AAAAI or ACAAI should be directed to the Executive Offices of the AAAAI, the ACAAI, or the Joint Council of Allergy, Asthma and Immunology. These parameters are not designed for use by pharmaceutical companies in drug promotion.
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Affiliation(s)
- Phillip Lieberman
- JointCouncil of Allergy, Asthma&Immunology, 50NBrockway St, #3-3, Palatine, IL 60067, USA.
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Cook TM, Scott S, Mihai R. Litigation related to airway and respiratory complications of anaesthesia: an analysis of claims against the NHS in England 1995-2007. Anaesthesia 2010; 65:556-563. [DOI: 10.1111/j.1365-2044.2010.06331.x] [Citation(s) in RCA: 106] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Expertise in allergy and immunology can aid other medical specialties. World Allergy Organ J 2009; 2:190-1. [PMID: 23283147 PMCID: PMC3651042 DOI: 10.1097/wox.0b013e3181b71c28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Cook TM, Bland L, Mihai R, Scott S. Litigation related to anaesthesia: an analysis of claims against the NHS in England 1995-2007. Anaesthesia 2009; 64:706-18. [DOI: 10.1111/j.1365-2044.2009.05913.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Florvaag E, Johansson SGO. IgE-mediated anaphylactic reactions to neuromuscular blocking agents: can they be prevented? Curr Allergy Asthma Rep 2008; 8:375-6. [PMID: 18682099 DOI: 10.1007/s11882-008-0072-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- E Florvaag
- Department of Clinical Immunology, Karolinska University Hospital, Solna, L2:04, S-171 76, Stockholm, Sweden.
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Schummer C, Wirsing M, Schummer W. The Pivotal Role of Vasopressin in Refractory Anaphylactic Shock. Anesth Analg 2008; 107:620-4. [DOI: 10.1213/ane.0b013e3181770b42] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
General anesthesia and anaphylaxis cause profound physiologic changes. When both occur simultaneously, it is often difficult to recognize and identify the medication or product responsible for the latter. Following such an event, the proper assessment, diagnosis, and recommendations are essential to prevent future reactions. This article reviews the more common causes of anaphylaxis during anesthesia.
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Affiliation(s)
- Thomas Chacko
- University of South Florida College of Medicine, 13000 Bruce B. Downs Boulevard, VAR 111D, Tampa, FL 33612, USA
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Currie M, Kerridge RK, Bacon AK, Williamson JA. Crisis management during anaesthesia: anaphylaxis and allergy. Qual Saf Health Care 2007; 14:e19. [PMID: 15933292 PMCID: PMC1744023 DOI: 10.1136/qshc.2002.004465] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Anaphylactic and anaphylactoid reactions during anaesthesia are a major cause for concern for anaesthetists. However, as individual practitioners encounter such events so rarely, the rapidity with which the diagnosis is made and appropriate management instituted varies considerably. OBJECTIVES To examine the role of a previously described core algorithm "COVER ABCD-A SWIFT CHECK", supplemented by a specific sub-algorithm for anaphylaxis, in the management of severe allergic reactions occurring in association with anaesthesia. METHODS The potential performance of this structured approach for each of the relevant incidents among the first 4000 reported to the Australian Incident Monitoring Study (AIMS) was compared with the actual performance as reported by the anaesthetists involved. RESULTS There were 148 allergic reactions among the first 4000 incidents reported to AIMS. It was considered that, properly applied, the structured approach would have led to a quicker and/or better resolution of the problem in 30% of cases, and would not have caused harm had it been applied in all of them. CONCLUSION An increased awareness of the diverse clinical manifestations of allergy seen in anaesthetic practice, together with the adoption of a structured approach to management should improve and standardise the treatment and improve follow up of patients suspected of having suffered a significant allergic reaction under anaesthesia.
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Affiliation(s)
- M Currie
- Goulburn Base Hospital, Goulburn, New South Wales, Australia
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Scherer K, Studer W, Figueiredo V, Bircher AJ. Anaphylaxis to isosulfan blue and cross-reactivity to patent blue V: case report and review of the nomenclature of vital blue dyes. Ann Allergy Asthma Immunol 2006; 96:497-500. [PMID: 16597088 DOI: 10.1016/s1081-1206(10)60921-0] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Blue dyes used for lymphatic mapping in sentinel lymph node biopsy cause intraoperative anaphylactic reactions in up to 2.7% of patients. With increasing implementation of this technique, the incidence of anaphylaxis to these dyes can be expected to increase. In the literature, the chemically often unrelated and inconsistently designated dyes have been confused, adding to other inconsistencies in the nomenclature. OBJECTIVE To demonstrate the nomenclature, chemical and physiologic differences, and allergenicity of the various blue dyes used in a medical context. METHODS We describe a patient with an intraoperative grade IV anaphylactic reaction to isosulfan blue. Immediate-type hypersensitivity was proved by positive skin test reactions and CD63 expression to isosulfan blue and cross-reactivity to patent blue V. RESULTS A review of the literature clarified the exact nomenclature of the blue dyes and the possible pitfalls of confusing nomenclature in the context of structurally closely related dyes with different allergenic properties. For the detection of type I hypersensitivity, intracutaneous tests are valuable tools. An IgE-mediated mechanism has been shown recently. In most cases, sensitization exists without known previous exposure in a medical context. This may be due to the widespread use of such dyes in objects of everyday life. Preoperative antiallergic medication use does not prevent anaphylactic reactions but apparently reduces their severity. CONCLUSION For better comparison and precision, the Chemical Abstracts Service number of the respective dye should always be given.
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Affiliation(s)
- Kathrin Scherer
- Allergy Unit, Department of Dermatology, University Hospital, Basel, Switzerland
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Mertes PM. Anaphylactic reactions during anaesthesia--let us treat the problem rather than debating its existence. Acta Anaesthesiol Scand 2005; 49:431-3. [PMID: 15777287 DOI: 10.1111/j.1399-6576.2005.00682.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Mast cells, which are granulocytes found in peripheral tissue, play a central role in inflammatory and immediate allergic reactions. beta-Tryptase is a neutral serine protease and is the most abundant mediator stored in mast cell granules. The release of beta-tryptase from the secretory granules is a characteristic feature of mast cell degranulation. While its biological function has not been fully clarified, mast cell beta-tryptase has an important role in inflammation and serves as a marker of mast cell activation. beta-Tryptase activates the protease activated receptor type 2. It is involved in airway homeostasis, vascular relaxation and contraction, gastrointestinal smooth muscle activity and intestinal transport, and coagulation. Serum mast cell beta-tryptase concentration is increased in anaphylaxis and in other allergic conditions. It is increased in systemic mastocytosis and other haematological conditions. Serum beta-tryptase measurements can be used to distinguish mast cell-dependent reactions from other systemic disturbances such as cardiogenic shock, which can present with similar clinical manifestations. Increased beta-tryptase levels are highly suggestive of an immunologically mediated reaction but may also occur following direct mast cell activation. Patients with increased mast cell beta-tryptase levels must be investigated for an allergic cause. However, patients without increased mast cell tryptase levels should be investigated if the clinical picture suggests severe anaphylaxis.
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Affiliation(s)
- V Payne
- Department of Anaesthesia, University of New South Wales, St George Hospital, Kogarah, NSW 2217, Australia
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Abstract
Neuromuscular blocking agents (NMBAs) play a predominant role in the incidence of severe adverse reactions occurring during anesthesia. Most hypersensitivity reactions are of immunologic origin (IgE-mediated) or are related to direct stimulation of histamine release. The incidence of IgE-mediated hypersensitivity or anaphylaxis is estimated between 1 in 10,000 and 1 in 20,000 anesthesias, and NMBAs represent the most frequently involved substances, with a range of 50% to 70%. Any suspected anaphylactic reaction must be extensively investigated using combined perioperative and postoperative testing. Because of the frequent cross-reactivity observed with muscle relaxants, every available NMBA should be tested. This should help provide documented advice for future administration of anesthesia. There is no demonstrated evidence for systematic preoperative screening in the general population at this time. Other well-known adverse effects have been described, such as the succinylcholine-triggered cytotoxic effects on muscle cells, but these are responsible for characteristic clinical symptoms, which are usually easy to distinguish from anaphylactic reactions
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Affiliation(s)
- Paul-Michel Mertes
- Département d'Anesthésie-réanimation, CHU de Nancy, Hôpital Central, 29 Avenue de Lattre de Tassigny, 54035 Nancy Cedex, France.
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Mertes PM, Dewachter P, Laxenaire MC. Complications anaphylactiques et anaphylactoïdes de l'anesthésie générale. ACTA ACUST UNITED AC 2004. [DOI: 10.1016/s0246-0289(03)00098-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Longrois D. [Management of anaphylactoid reactions associated with anesthesia, and treatment of anaphylactic shock]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2002; 21 Suppl 1:168s-180s. [PMID: 12091981 DOI: 10.1016/s0750-7658(01)00554-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- D Longrois
- Département d'anesthésie-réanimation chirurgicale, CHU Nancy-Brabois, 4, rue du Morvan, 54511 Vandoeuvre-les-Nancy, France.
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Laxenaire MC. [What is the real risk of drug hypersensitivity in anesthesia? Incidence. Clinical aspects. Morbidity-mortality. Substances responsible]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2002; 21 Suppl 1:38s-54s. [PMID: 12091986 DOI: 10.1016/s0750-7658(01)00560-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- M C Laxenaire
- Département d'anesthésie-réanimation chirurgicale, hôpital central, CHU, 29, avenue du Maréchal de Lattre-de-Tassigny, CO no. 34, 54035 Nancy, France.
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Jacobsen J, Lindekaer AL, Ostergaard HT, Nielsen K, Ostergaard D, Laub M, Jensen PF, Johannessen N. Management of anaphylactic shock evaluated using a full-scale anaesthesia simulator. Acta Anaesthesiol Scand 2001; 45:315-9. [PMID: 11207467 DOI: 10.1034/j.1399-6576.2001.045003315.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND The diagnosis of an anaphylactic reaction during anaesthesia is not the first consideration for the anaesthetist and might be missed. The aim of this study was to describe anaesthetists' management of an anaphylactic reaction concerning diagnosing, treatment and application of anaesthesia crisis resource management (ACRM) in a full-scale anaesthesia simulator. METHODS Forty-two anaesthetists in teams of two attended training sessions with a critical incident of anaphylactic shock in a full-scale simulator. Trained observers from the study group evaluated the medical treatment according to a treatment sequence developed from the literature and graded the ACRM performance on a five-point scale where 1 is bad and 5 is best. RESULTS None of the teams made the correct diagnosis within 10 min and treatment according to the treatment sequence was not initiated. Only 6/21 teams considered the right diagnosis but first after hints from the instructor 15 min after the start of the incident. Evaluation of the use of the total ACRM concept (that is the use of all of the ACRM expressions seen in a total connection: called general impression) gave a median value of 2.0 with a range of (1-3). CONCLUSION Anaphylactic shock was difficult to diagnose and no structured plans were used for the treatment in the simulated incident in this study.
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Affiliation(s)
- J Jacobsen
- Department of Anaesthesiology, Herlev Hospital, University of Copenhagen, Denmark
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Foxell RM. Incidence of anaphylaxis under anaesthesia. Anaesthesia 2001; 56:294-5. [PMID: 11251470 DOI: 10.1046/j.1365-2044.2001.01918-34.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Yoshida SH, Siu J, Griffey SM, German JB, Gershwin ME. Dietary Juniperis virginiensis seed oil decreased pentobarbital-associated mortalities among DBA/1 mice treated with collagen-adjuvant emulsions. JOURNAL OF LIPID MEDIATORS AND CELL SIGNALLING 1996; 13:283-93. [PMID: 8816989 DOI: 10.1016/0929-7855(95)00060-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The propensity of the fatty acid 5,11,14-eicosatrienoic acid (5,11,14-ETA) to replace arachidonic acid in cell membranes, and its inability to be converted to bioactive eicosanoids, suggest that it may be useful in the treatment of autoimmune disorders. Previously, dietary application of oils extracted from 5,11,14-ETA-rich Platycladus orientalis delayed the onset of autoimmune disease in New Zealand Black mice. To gain more knowledge of the efficacy of this fatty acid toward alleviating immunological disorders, a similar oil was used to examine its effects on collagen-induced arthritis in DBA/1 mice, a model characterized by synovial proliferation and joint infiltration by inflammatory cells. Mice were fed AIN76A diet supplemented with 4% (w/w) of either an oil extracted from the seeds of Juniperis virginiensis (0.4% 5,11,14-ETA); a control oil consisting of equal parts olive, linseed and safflower oils; fish oil (90% fish oil and 10% safflower oil); or safflower oil. Mice were immunized with three injections of collagen-adjuvant emulsions, the first injection was intradermal, and the two subsequent injections were intraperitoneal. Mortalities were recorded following a secondary pentobarbital administration intraperitoneally. Mice from the J. virginiensis group had the lowest mortalities (25%) while safflower oil-fed mice had the highest (59%; p < 0.05). While the J. virginiensis group had the lowest mean CD4/CD8 T lymphocyte ratio, the fish oil group had the highest. These observations suggest that manipulation of eicosanoid production by different dietary lipids had different effects on immune responses, possibly through alterations in T lymphocyte subsets. Hypothetically, a downregulation of prostaglandin E2 release could increase the ratio of T helper 1 to T helper 2 lymphocytes and thereby modulate anaphylactic responses. Also, lowered pro-oxidant status may decrease CD4/CD8 T cell ratios and modify immune function.
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Affiliation(s)
- S H Yoshida
- Department of Food Science and Technology, University of California, Davis 95616-859, USA
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Runciman WB, Webb RK, Barker L, Currie M. The Australian Incident Monitoring Study. The pulse oximeter: applications and limitations--an analysis of 2000 incident reports. Anaesth Intensive Care 1993; 21:543-50. [PMID: 8273873 DOI: 10.1177/0310057x9302100509] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The first 2000 incidents reported to the Australian Incident Monitoring Study were analysed with respect to the role of the pulse oximeter. Of these 184 (9%) were first detected by a pulse oximeter and there were a further 177 (9%) in which desaturation was recorded. Of the 1256 incidents which occurred in association with general anaesthesia 48% were "human detected" and 52% "monitor detected". The pulse oximeter was ranked first and detected 27% of these monitor detected incidents; this figure would have been over 40% if an oximeter had always been used and its more informative modulated pulse tone relied upon instead of that of the "bleep" of the ECG. The pulse oximeter is the "front-line" monitor for endobronchial intubation, the fourth most common incident in association with general anaesthesia (it detected 87% of the 76 cases in which it was in use). It also played an invaluable role as a "back-up" monitor in 40 life-threatening situations in which "front-line" monitors (e.g. oxygen analyser, low pressure alarm, capnograph) were either not in use, were being used incorrectly or failed. Other situations detected, in order of frequency of detection, were: circuit disconnection, circuit leak, desaturation (severe shunt), oesophageal intubation, aspiration and/or regurgitation, pulmonary oedema, endotracheal tube obstruction, severe hypotension, failure of oxygen delivery, hypoxic gas mixture, hypoventilation, anaphylaxis, air embolism, bronchospasm, malignant hyperthermia, and tension pneumothorax.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- W B Runciman
- Department of Anaesthesia and Intensive Care, University of Adelaide, S.A
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Morgan CA, Webb RK, Cockings J, Williamson JA. The Australian Incident Monitoring Study. Cardiac arrest--an analysis of 2000 incident reports. Anaesth Intensive Care 1993; 21:626-37. [PMID: 8273887 DOI: 10.1177/0310057x9302100523] [Citation(s) in RCA: 29] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Eighty-seven cases of cardiac arrest from the first 2000 incidents reported to the Australian Incident Monitoring Study were reviewed. "Cardiac arrest" was taken to include patients who were either pulseless or had electrocardiographic asystole or ventricular fibrillation. Cases were grouped by primary cause--drug administration (19), vagal stimulation (16), hypoventilation (15), bleeding (13), anaphylaxis (6), direct cardiac stimulation (4) and miscellaneous (14). Overall, 20 patients died (23% of the 87 cases); all of these were in the hypoventilation, bleeding, or miscellaneous groups (4, 9 and 7 patients, respectively). Cardiac compression was performed in 66% of patients; 20% were defibrillated; adrenaline was given to 42% and bicarbonate to 3%. There was a clear anaesthetic cause for 46% of this series of arrests, and with hindsight, a preventable factor was present in over half (58%) of these. Preventative strategies regarding staffing, equipment, policy and procedures are suggested.
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Affiliation(s)
- C A Morgan
- Royal Victorian Eye and Ear Hospital, Melbourne, South Australia
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Williamson JA, Webb RK, Sellen A, Runciman WB, Van der Walt JH. The Australian Incident Monitoring Study. Human failure: an analysis of 2000 incident reports. Anaesth Intensive Care 1993; 21:678-83. [PMID: 8273898 DOI: 10.1177/0310057x9302100534] [Citation(s) in RCA: 133] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Information of relevance to human failure was extracted from the first 2,000 incidents reported to the Australian Incident Monitoring Study (AIMS). All reports were searched for human factors amongst the "factors contributing," "factors minimising", and "suggested corrective strategies" categories, and these were classified according to the type of human error with which they were associated. In 83% of the reports elements of human error were scored by reporters. "Knowledge-based errors" contributed directly to about one-quarter of incidents; the outcome of one third of incidents was thought to have been minimised by prior experience or awareness of the potential problems, and in one fifth some strategy to improve knowledge was suggested. Correction of "rule-based errors" or provision of protocols or algorithms were thought, together, to have a potential impact on nearly half of all incidents. Failure to check equipment or the patient contributed to nearly one-quarter of all incidents, and inadequate crisis management contributed to a further 1 in 8. "Skill-based errors" (slips and lapses) were directly responsible for 1 in 10 of all incidents, and were thought to make an indirect contribution in up to one quarter. "Technical errors" were responsible for about 1 in 8 incidents. Analysing the relative contribution of each type of error for each type of problem allows the development of rational preventative strategies.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- J A Williamson
- Department of Anaesthesia and Intensive Care, University of Adelaide and Royal Adelaide Hospital, South Australia
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Runciman WB, Webb RK, Klepper ID, Lee R, Williamson JA, Barker L. The Australian Incident Monitoring Study. Crisis management--validation of an algorithm by analysis of 2000 incident reports. Anaesth Intensive Care 1993; 21:579-92. [PMID: 8273879 DOI: 10.1177/0310057x9302100515] [Citation(s) in RCA: 77] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Anaesthetists are called upon to manage complex life-threatening crises at a moment's notice. As there is evidence that this may require cognitive tasking beyond the information-processing capacity of the human brain, it was decided to try and develop a generic crisis management algorithm analogous to the "Phase I" immediate response routine used by airline pilots. Such an algorithm, based on the mnemonic "COVER ABCD, A SWIFT CHECK", was developed and refined over 3 meetings, each attended by 60-100 anaesthetists and aviation psychologists. It was validated against 1301 relevant incidents among the first 2000 incidents reported to the Australian Incident Monitoring Study. It proved sufficiently robust and safe to recommend its general use as an initial response to any incident or crisis which occurs when a patient is breathing gas from an anesthetic machine. It requires a limited knowledge base and is easily learnt and rehearsed during the anaesthetist's working day. It will provide a functional diagnosis in over 99% of cases and will correct 62% of the problems in 40-60 seconds. In the remaining 37% it will allow the anaesthetist to proceed with a "sub-algorithm", confident in the knowledge that some important step has not been missed. In just over 30% of incidents this will be for a problem familiar to all anaesthetists (e.g. laryngospasm, bradycardia); in just over 6% it will be for a less common, more complex, but finite, set of problems (3% cardiac arrest, 1% air embolism, 1% anaphylaxis, 1% for the remaining desaturations); in less than 1% diagnosis and correction will require a more complex checklist (e.g. for malignant hyperthermia, pneumothorax). The next stage, the development of specific sub-algorithms and a structured team approach for ongoing problems, is in progress.
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Affiliation(s)
- W B Runciman
- Department of Anaesthesia and Intensive Care, University of Adelaide, S.A
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Runciman WB, Webb RK, Lee R, Holland R. The Australian Incident Monitoring Study. System failure: an analysis of 2000 incident reports. Anaesth Intensive Care 1993; 21:684-95. [PMID: 8273899 DOI: 10.1177/0310057x9302100535] [Citation(s) in RCA: 75] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Although 70-80% of problems have some component of human error, its overall contribution to many problems may be small; studies of complex systems have revealed that up to 85% are primarily due to deficiencies in the lay-out and processes of the system. The anaesthetist has to operate in a complex system; many problems originate from deficiencies in this system. Information of relevance to system failure was extracted from the first 2000 incidents reported to the Australian Incident Monitoring Study (AIMS). A system-based deficiency directly contributed to one-quarter of problems (four-fifths if human factors are included), some aspect of the system minimized the adverse outcome in over half of all cases (four-fifths if human factors are included), and in two-thirds (three-quarters if human factors are included) a system-based strategy would have been helpful; the system was implicated in 90% of all incidents (97% if human factors are included). Regardless of whether or not all human error should be regarded as part of the "system", attempts to modify its incidence and nature have to emanate from the system. AIMS reporting pathways and the organizations involved in developing and implementing strategies to improve the system operate at four levels. Level I involves the use of AIMS reports by hospitals and group practices for audit at a local level. Level II involves AIMS participants sending forms to the AIMS central office; collated information is then sent back to contributors by newsletter. Level III involves interaction between AIMS and the major professional bodies and level IV interaction between AIMS, these bodies and a variety of national and international agencies. Over 100 topics were identified from the AIMS data for consideration at one or more of these levels. AIMS has the potential not only to play a vital practical role in the continued enhancement of the quality of anaesthetic practice, but also to provide a valuable resource for research at the increasingly important interface between human behaviour and complex systems.
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Affiliation(s)
- W B Runciman
- Department of Anaesthesia and Intensive Care, University of Adelaide, S.A
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Webb RK, Currie M, Morgan CA, Williamson JA, Mackay P, Russell WJ, Runciman WB. The Australian Incident Monitoring Study: an analysis of 2000 incident reports. Anaesth Intensive Care 1993; 21:520-8. [PMID: 8273871 DOI: 10.1177/0310057x9302100507] [Citation(s) in RCA: 267] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The Australian Patient Safety Foundation was formed in 1987; it was decided to set up and co-ordinate the Australian Incident Monitoring Study as a function of this Foundation; 90 hospitals and practices joined the study. Participating anaesthetists were invited to report, on an anonymous and voluntary basis, any unintended incident which reduced, or could have reduced, the safety margin for a patient. Any incident could be reported, not only those which were deemed "preventable" or were thought to involve human error. The Mark I AIMS form was developed which incorporated features and concepts from several other studies. All the incidents in this symposium were reported using this form, which contains general instructions to the reporter, key words and space for a narrative of the incident, structured sections for what happened (with subsections for circuitry incidents, circuitry involved, equipment involved, pharmacological incidents and airway incidents), why it happened (with subsections for factors contributing to the incident, factors minimising the incident and suggested corrective strategies), the type of anaesthesia and procedure, monitors in use, when and where the incident happened, the experience of the personnel involved, patient age and a classification of patient outcome. Enrollment, reporting and data-handling procedures are described. Data on patient outcome are presented; this is correlated with the stages at which the incident occurred and with the ASA status of the patients. The locations at which the incidents occurred and the types of procedures, the sets of incidents analysed in detail and a breakdown of the incidents due to drugs are also presented.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- R K Webb
- Department of Anaesthesia and Intensive Care, University of Adelaide, South Australia
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