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Garvey LH, Dewachter P, Hepner DL, Mertes PM, Voltolini S, Clarke R, Cooke P, Garcez T, Guttormsen AB, Ebo DG, Hopkins PM, Khan DA, Kopac P, Krøigaard M, Laguna JJ, Marshall S, Platt P, Rose M, Sabato V, Sadleir P, Savic L, Savic S, Scherer K, Takazawa T, Volcheck GW, Kolawole H. Management of suspected immediate perioperative allergic reactions: an international overview and consensus recommendations. Br J Anaesth 2019; 123:e50-e64. [DOI: 10.1016/j.bja.2019.04.044] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 04/04/2019] [Accepted: 04/14/2019] [Indexed: 12/11/2022] Open
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Comparative epidemiology of suspected perioperative hypersensitivity reactions. Br J Anaesth 2019; 123:e16-e28. [PMID: 30916015 DOI: 10.1016/j.bja.2019.01.027] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 12/24/2018] [Accepted: 01/15/2019] [Indexed: 12/31/2022] Open
Abstract
Suspected perioperative hypersensitivity reactions are rare but contribute significantly to the morbidity and mortality of surgical procedures. Recent publications have highlighted the differences between countries concerning the respective risk of different drugs, and changes in patterns of causal agents and the emergence of new allergens. This review summarises recent information on the epidemiology of perioperative hypersensitivity reactions, with specific consideration of differences between geographic areas for the most frequently involved offending agents.
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Pedersen AF, Green S, Rose MA. Failure to Investigate Anaesthetic Anaphylaxis Resulting in a Preventable Second Anaphylactic Reaction. Anaesth Intensive Care 2019. [DOI: 10.1177/0310057x1204000619] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- A. F. Pedersen
- Department of Anaesthesia, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - S. Green
- Department of Anaesthesia, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - M. A. Rose
- Department of Anaesthesia, Royal North Shore Hospital, Sydney, New South Wales, Australia
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Lee CH, Lim BG, Cho SI, Lee SH, Mun SH, Lee IO. Consecutive anaphylaxis due to rocuronium and cisatracurium during general anesthesia -A case report-. Anesth Pain Med (Seoul) 2016. [DOI: 10.17085/apm.2016.11.4.384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Chung Hun Lee
- Department of Anesthesiology and Pain Medicine, Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Byung Gun Lim
- Department of Anesthesiology and Pain Medicine, Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Seung Inn Cho
- Department of Anesthesiology and Pain Medicine, Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - So Hyun Lee
- Department of Anesthesiology and Pain Medicine, Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Suk Hee Mun
- Department of Anesthesiology and Pain Medicine, Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Il Ok Lee
- Department of Anesthesiology and Pain Medicine, Guro Hospital, Korea University College of Medicine, Seoul, Korea
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Abstract
The aim of this article is to provide an overview on neuromuscular blocking agents and a rational selection of the most appropriate agents, along with pharmacological and pharmacoeconomic considerations on neuromuscular blockers and their antagonists. Neuromuscular blocking agents are used during anesthesia to facilitate endotracheal intubation and provide surgically required paralysis. There is continuing development in the field of neuromuscular blocking agents, with new products appearing at regular intervals. All new agents come at increased costs. The proportion of anesthesia-related drug costs on a per-patient basis are small and vary from country to country, but account for no more than 12% of hospital drug budgets. However, given the large number of anesthetics performed over time, the total cost is significant. Moreover, such costs should be put into the perspective of the operating theater and patient admission costs. Appropriate selection of neuromuscular blocking agents can help not only to reduce biological costs secondary to complications, but also to make operating lists proceed smoothly and without incident. The paucity of outcome studies in relation to anesthetic drugs is not surprising given that anesthesia is used to facilitate the provision of therapy rather than being therapeutic in its own right. Accordingly, the assessment of anesthetic drugs has a different priority to therapeutic drugs. As anesthetic drugs are nontherapeutic, it is also difficult to determine the best choice of agent. However, new neuromuscular blocking agents are marketed on the basis of improvements in the frequency of side effects, safety, reliability, duration, reversibility and undesirable hemodynamic effects.
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Affiliation(s)
- Yigal Leykin
- Santa Maria degli Angeli Hospital, Department of Anesthesia and Intensive Care, Via Montereale 24, 33170 Pordenone, Italy.
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Aranda A, Mayorga C, Ariza A, Doña I, Rosado A, Blanca-Lopez N, Andreu I, Torres MJ. In vitro evaluation of IgE-mediated hypersensitivity reactions to quinolones. Allergy 2011; 66:247-54. [PMID: 20722637 DOI: 10.1111/j.1398-9995.2010.02460.x] [Citation(s) in RCA: 119] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Hypersensitivity IgE-mediated reactions to quinolones are not easy to diagnose, with skin testing inducing false positive results. The aim of the study was to evaluate the in vitro-specific IgE response in patients with immediate allergic reactions to quinolones. METHODS We evaluated 38 patients with confirmed immediate allergic reactions to quinolones. Those with anaphylaxis were considered allergic by clinical history, once other possible causes were ruled out, and those with urticaria by drug provocation. Sepharose-radioimmunoassay (RIA) and basophil activation test (BAT) with ciprofloxacin, moxifloxacin and levofloxacin were performed. RESULTS The quinolones involved were moxifloxacin (N = 24), ciprofloxacin (N = 11) and levofloxacin (N = 3). Sepharose-RIA was positive in 12 cases (31.57%) and BAT in 27 (71.05%). With Sepharose-RIA, 8 (21%) were positive to ciprofloxacin, 7 (18.4%) to moxifloxacin and 7 (18.4%) to levofloxacin. With BAT, 23 (60.5%) were positive to ciprofloxacin, 12 (31.6%) to moxifloxacin and 8 (21%) to levofloxacin. The specificity of the Sepharose-RIA was demonstrated by inhibition tests. To confirm that the BAT results observed were IgE mediated, the PI3K inhibitor wortmannin was used, with this compound inhibiting the BAT when stimulated with anti-IgE and the different quinolones, but not when fMLP was used as the basophil stimulator. Sepharose-RIA and BAT were repeated in positive cases 1 year later, detecting a decrease in all cases, with four becoming negative. CONCLUSION Immediate hypersensitivity reactions to quinolones do occur, with moxifloxacin being the drug most frequently involved. The BAT is a useful method for diagnosing patients. Specific IgE was demonstrated by Sepharose-RIA and inhibition assay.
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Affiliation(s)
- A Aranda
- Research Unit for Allergic Diseases, Malaga, Spain
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De Amici M, Villani M, Milanesi E, Rossini B, Barco S, Gerletti M, Ciprandi G. Adverse Reactions to Anaesthetics Prevented by the Use of Specific Laboratory Tests. EUR J INFLAMM 2011; 9:79-81. [DOI: 10.1177/1721727x1100900112] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2023] Open
Abstract
Adverse reactions to general anaesthetics are quite rare, but may be very severe and even lethal. Unfortunately, the diagnosis is frequently based on medical history and few laboratory tests are reliable. A clinical case is presented: a patient, 75 years of age, was a candidate for urgent coronary artery bypass graft surgery due to the results of the coronary angiogram (severe stenosis of the main stem). The patient reported cardiac arrest in both operations with general anaesthesia, but there was a lack of clinical documentation. Thus, sulfidoleukotriene assay (CAST-ELISA, Bühlmann Laboratories) was used to determine the tolerability of general anesthetics in a single patient. The results of this in vitro test was useful in discriminating and excluding the administration of some widely-used standard anaesthetic agents.
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Affiliation(s)
- M. De Amici
- Fondazione IRCCS Policlinico San Matteo, S.C. di Pediatria, Pavia
| | - M.A. Villani
- Fondazione IRCCS Policlinico San Matteo, Rianimazione III, Pavia
| | - E. Milanesi
- Fondazione IRCCS Policlinico San Matteo, Rianimazione III, Pavia
| | - B. Rossini
- Fondazione IRCCS Policlinico San Matteo, Rianimazione III, Pavia
| | - S. Barco
- Fondazione IRCCS Policlinico San Matteo, S. C. Angiologia, Malattie Tromboemboliche, Pavia
| | - M. Gerletti
- Fondazione IRCCS Policlinico San Matteo, Rianimazione III, Pavia
| | - G. Ciprandi
- Department of Internal Medicine, Azienda Ospedaliera Universitaria San Martino, University of Genoa, Genoa
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Mcneill O, kerridge RK, Boyle MJ. Review of Procedures for Investigation of Anaesthesia-Associated Anaphylaxis in Newcastle, Australia. Anaesth Intensive Care 2008; 36:201-7. [DOI: 10.1177/0310057x0803600210] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The procedures, results and outcomes of investigation of 50 patients with clinical episodes of anaesthesia-associated anaphylaxis were retrospectively reviewed. Assessment was performed by measurement of serum tryptase and specific IgE and a combination of skin prick and intradermal skin testing. Testing was performed both for agents received during the anaesthetic and for agents the patient may encounter in future procedures. Twenty of 50 patients underwent a subsequent procedure after assessment. Sensitisation to neuromuscular blocking agents was identified in 18 patients (36%). Sensitisation to propofol (14 patients; 28%) and latex (four patients; 8%) was also frequently identified. No precise cause was identified in 11 cases (22%). Reactivity to more than one agent was identified in 14 patients (28%). Serum tryptase was measured within six hours of the episode in only 28 of the 50 cases. All the patients with elevated serum tryptase had clinically severe reactions. One patient initially found to be sensitised to propofol had another reaction during a second procedure, prompting further assessment where chlorhexidine reactivity was identified. Subsequent surgery in that patient and in 19 other patients where agents implicated in the testing were avoided, proceeded without incident. The results reaffirm that neuromuscular blocking agents are the most common cause of anaphylaxis during anaesthesia. The importance of serum tryptase measurement at the time of the acute episode needs to be emphasised. Investigation should include screening for chlorhexidine and latex in all patients, as exposure to both these agents is common and may be overlooked.
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Affiliation(s)
- O. Mcneill
- Departments of Immunology and Anaesthesia, John Hunter Hospital, Newcastle, New South Wales, Australia
- Department of Immunology
| | - R. K. kerridge
- Departments of Immunology and Anaesthesia, John Hunter Hospital, Newcastle, New South Wales, Australia
- Perioperative Service, Department of Anaesthesia
| | - M. J. Boyle
- Departments of Immunology and Anaesthesia, John Hunter Hospital, Newcastle, New South Wales, Australia
- Department of Immunology
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Shinn HK, Lim HK, Song JH, Han JU, Ko DH, Jung IJ, Jung JK. Anaphylaxis by vecuronium during induction of general anesthesia - A case report -. Korean J Anesthesiol 2008. [DOI: 10.4097/kjae.2008.55.5.613] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Helen Ki Shinn
- Department of Anesthesiology and Pain Medicine, Inha University College of Medicine, Incheon, Korea
| | - Hyun Kyoung Lim
- Department of Anesthesiology and Pain Medicine, Inha University College of Medicine, Incheon, Korea
| | - Jang-Ho Song
- Department of Anesthesiology and Pain Medicine, Inha University College of Medicine, Incheon, Korea
| | - Jeong Uk Han
- Department of Anesthesiology and Pain Medicine, Inha University College of Medicine, Incheon, Korea
| | - Du-Hyun Ko
- Department of Anesthesiology and Pain Medicine, Inha University College of Medicine, Incheon, Korea
| | - In-Jun Jung
- Department of Anesthesiology and Pain Medicine, Inha University College of Medicine, Incheon, Korea
| | - Jong-Kwon Jung
- Department of Anesthesiology and Pain Medicine, Inha University College of Medicine, Incheon, Korea
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10
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Abstract
Correct management of anaphylaxis during anaesthesia requires a multidisciplinary approach with prompt recognition and treatment of the acute event by the attending anaesthesiologist, and subsequent determination of the responsible agent(s) with strict avoidance of subsequent administration of all incriminated and/or cross-reacting compounds. However, correct identification of the causative compound(s) and safe alternatives is not always straightforward and, too often, not done. This review is not intended to discuss acute management of anaesthesia-related anaphylaxis but summarizes the major causes of anaphylaxis during anaesthesia and the diagnostic approach of this rare but potentially life-threatening complication. Apart from general principles about the diagnostic approach, history taking and importance of tryptase quantification, more specific confirmatory diagnostic procedures are organized on the basis of the major causes of perioperative anaphylactic reactions.
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Affiliation(s)
- D G Ebo
- Department of Immunology, Allergology and Rheumatology, University of Antwerp, Antwerpen, Belgium
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11
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Scala E, Guerra EC, Giani M, Pirrotta L, Locanto M, Mondino C, Mari A. Delayed Allergic Reaction to Suxamethonium Driven by Oligoclonal Th1-Skewed CD4+CCR4+IFN-γ+ Memory T Cells. Int Arch Allergy Immunol 2006; 141:24-30. [PMID: 16804321 DOI: 10.1159/000094178] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2005] [Accepted: 02/21/2006] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Muscle relaxants represent the drugs most frequently involved in intraoperative anaphylaxis during surgical procedures. Our aim was to report the case of a delayed reaction to suxamethonium and analyze specific T cell lines with regard to their specificity, phenotype and cytokine profile. METHODS We generated a drug-specific T cell line from a biopsy at the site of positive intradermal reactions and analyzed the immunophenotype, T cell receptor Vbeta domain expression and cytokine profile. RESULTS T cells isolated from positive intradermal test reactions to suxamethonium showed a strict dose-dependent proliferation in response to drug-pulsed autologous antigen-presenting cells. The drug-specific CD4+ T cells were oligoclonal memory CD3+CD4+ T cells and expressed the skin homing receptors cutaneous lymphocyte antigen (CLA) and CCR4. Furthermore CD4+ suxamethonium-reactive T cell lines were IFN-gamma-positive and synthesized high levels of IFN-gamma and TNF-alpha. CONCLUSION The study describes a delayed hypersensitivity to suxamethonium, driven by an oligoclonal T helper cell 1-skewed CD4+ memory T cell population, expressing the skin homing receptors CLA and CCR4.
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Affiliation(s)
- Enrico Scala
- Istituto Dermopatico dell'Immacolata - IDI, Experimental Allergology Unit, Rome, Italy.
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12
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Ebo DG, Bridts CH, Hagendorens MM, Mertens CH, De Clerck LS, Stevens WJ. Flow-assisted diagnostic management of anaphylaxis from rocuronium bromide. Allergy 2006; 61:935-9. [PMID: 16867045 DOI: 10.1111/j.1398-9995.2006.01094.x] [Citation(s) in RCA: 87] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Diagnosis of anaphylaxis from neuromuscular blocking agents (NMBA) is not always straightforward. OBJECTIVES To assess flow cytometric analysis of activated basophils (BAT) as a diagnostic instrument in anaphylaxis from rocuronium. To investigate whether the technique might help to identify cross-reactive and safe alternative compounds. METHODS For validation of the BAT, 14 patients with perioperative anaphylaxis demonstrating a positive skin test (ST) for rocuronium and eight individuals that tolerated rocuronium and a negative ST for this drug were enrolled. To confirm specificity of the BAT, five patients that tolerated atracurium or cisatracurium with a negative ST for rocuronium were tested. Basophil activation with rocuronium, vecuronium, atracurium, cisatracurium and suxamethonium was analysed flow cytometrically by labelling with anti-CD123/anti-HLADR/anti-CD63. RESULTS Sensitivity of BAT for rocuronium was 91.7% and specificity 100%. However, in two patients the BAT was lost as a diagnostic tool, as their cells were nonresponsive to positive control stimulation and allergen. Seven from the 12 responsive patients also demonstrated a clear basophilic activation for vecuronium. Moreover, according to ST and/or BAT cross-reactivity between rocuronium and vecuronium was suspected in 10/14 patients. Except one patient, all patients had negative BAT and ST investigations for atracurium and cisatracurium. Currently, five patients tolerated administration of cisatracurium. All control individuals demonstrated negative ST and BAT for all tested NMBA. CONCLUSIONS The BAT constitutes a reliable instrument to diagnose anaphylaxis from rocuronium. The technique also allows quick and simultaneous testing of different potential cross-reactive NMBA and to tailor a safe alternative.
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Affiliation(s)
- D G Ebo
- Department of Immunology, Allergology and Rheumatology, University of Antwerp, Antwerp, Belgium
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13
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Freiler JF, Steel KE, Hagan LL, Rathkopf MM, Roman-Gonzalez J. Intraoperative anaphylaxis to bacitracin during pacemaker change and laser lead extraction. Ann Allergy Asthma Immunol 2005; 95:389-93. [PMID: 16279570 DOI: 10.1016/s1081-1206(10)61158-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Bacitracin is widely used in operating rooms to soak implants, irrigate compound fractures, and apply to surgical incisions. However, bacitracin is a known sensitizer and causes not only allergic contact dermatitis but also anaphylaxis. OBJECTIVE To describe a 72-year-old woman with anaphylaxis after irrigation and packing of an infected pacemaker pocket with a bacitracin solution. METHODS Skin prick testing to bacitracin and latex; serum tryptase, serum histamine, serum IgE to latex, and serial cardiac enzyme measurements; blood cultures, transthoracic echocardiograms, and venograms were performed to characterize the reaction. RESULTS Six hours after the anaphylactic event, the patient had an elevated serum tryptase level of 49 ng/mL (reference range, 2-10 ng/mL), which normalized the next morning. She had immediate-type skin prick test reactions to full-strength bacitracin ointment (500 U/g) and bacitracin solution (150 U/mL). Serum IgE level to latex was undetectable, and results of skin testing to latex were negative. CONCLUSIONS To our knowledge, this is the first case report of anaphylaxis to bacitracin during pacemaker surgery. This case illustrates that intraoperative anaphylaxis to bacitracin can be life-threatening.
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Affiliation(s)
- John F Freiler
- Department of Allergy/Immunology, Wilford Hall Medical Center, Lackland AFB, Texas 78236, USA.
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Ebo DG, Hagendorens MM, Bridts CH, Stevens WJ. Immediate-type allergy to drugs and related compounds: evaluation and management. Acta Clin Belg 2005; 60:350-61. [PMID: 16502596 DOI: 10.1179/acb.2005.053] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Adverse drug reactions (ADR) constitute a major health issue in outpatient and inpatient clinical settings. An allergic drug reaction is an immunologically mediated adverse drug reaction that exhibits specificity and recurrence on re-exposure to the offending and/or cross-reactive compound(s). Diagnosis of drug allergy is difficult, as a broad spectrum of different drugs can elicit various immune-mediated diseases with distinct (sometimes unclear) pathomechanism, the exact structure (epitope) that causes the reaction is frequently unknown, the presence of an in vitro or in vivo test results might not be predictive of a clinical situation, and the gold standard or reference test for diagnosis, the drug challenge, is a complicated and sometimes dangerous endeavour. Nevertheless, during the past few years serious attempts have been made to standardise and validate in vitro and in vivo techniques for the diagnosis of drug allergy. New techniques, e.g. flow-assisted analysis of in vitro basophil activation, are replacing older ones like histamine release for immediate-type hypersensitivity reactions. However, additional comprehensive studies are required to further validate the technique and allow its entrance in mainstream diagnostic use, particularly for non-IgE-mediated hypersensitivity. This review attempts to summarize the major causes of immediate hypersensitivity reactions to drugs and related compounds. Special attention is paid to the diagnostic and therapeutic management of this common iatrogenic complication.
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Affiliation(s)
- D G Ebo
- Dept Immunology, Allergology, Rheumatology, University Antwerp, Belgium
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15
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Bhananker SM, O'Donnell JT, Salemi JR, Bishop MJ. The Risk of Anaphylactic Reactions to Rocuronium in the United States Is Comparable to That of Vecuronium: An Analysis of Food and Drug Administration Reporting of Adverse Events. Anesth Analg 2005; 101:819-822. [PMID: 16115997 DOI: 10.1213/01.ane.0000175213.87556.d8] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Published reports from France and Norway suggest a frequent incidence of anaphylaxis to rocuronium and have raised concerns about its safety. We hypothesized that the Food and Drug Administration Adverse Event Reporting System could be used to confirm whether there has been an unusual incidence of anaphylactic events for rocuronium in the United States (U.S.) and whether the reporting patterns differ within and outside of the U.S.. We queried the Food and Drug Administration Adverse Event Reporting System for 1999 through the first quarter of 2002 for all adverse events for the drugs rocuronium and vecuronium and then searched on the terms considered to represent possible anaphylaxis using proprietary software. We compared the frequency of these terms in data both for rocuronium and vecuronium. We then assessed the occurrence of reports of anaphylaxis-related terms in reports from the U.S. compared with reports originating outside of the U.S.. For rocuronium, the database contained 311 reports, 166 domestic and 145 from foreign sources. Fifty percent of the foreign reports contained an anaphylaxis term versus 20% of the domestic reports (P < 0.001). For vecuronium, the comparable figures were 17% and 19% (not significant) and the total number of reports was 243. The incidence of the reports containing anaphylaxis terms did not differ between vecuronium and rocuronium in the U.S. but were significantly different for foreign reports (P < 0.001). These data confirm that U.S. anesthesia providers have not observed a significant difference in anaphylactic reactions between the two commonly used intermediate-acting muscle relaxants and suggest that frequency of reports of anaphylaxis may be significantly influenced by the area from which the reports originate.
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Affiliation(s)
- Sanjay M Bhananker
- *Department of Anesthesiology, University of Washington School of Medicine, Seattle, WA; †Department of Pharmacology, Rush Medical College, Chicago, IL; ‡Pharmaconsultant, Inc., Palatine, IL; and §Department of Veterans Affairs and the Departments of Anesthesiology and Medicine (adjunct, Pulmonary and Critical Care), University of Washington School of Medicine, Seattle, WA
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