Perioperative Management of a Patient with Cold Urticaria

Cold-induced anaphylaxis triggered by drinking cold water

Cold urticaria is an inducible urticaria in which hives and angioedema appear after exposure to cold. The symptoms of cold urticaria often are limited to hives/angioedema. However, in up to 20% of cases, cold exposure may trigger anaphylaxis. We report the case of an 11-year-old boy previously diagnosed with chronic spontaneous urticaria who developed facial swelling, itchy hives, difficulty in breathing, vomiting and abdominal pain within 5 minutes of drinking cold water. He received a standard dose of non-sedating second-generation antihistamines at home. He was observed in the emergency room for 2 hours and discharged with an epinephrin autoinjector. During the subsequent outpatient clinic visit, an ice cube test was performed which confirmed the new diagnosis of comorbid cold-induced chronic urticaria. On further questioning, the parents reported occurrence of hives following swimming in the swimming pool. Cold-induced urticaria should be suspected in cases of anaphylaxis associated with cold exposure. Patients with chronic forms of urticaria who present with new anaphylaxis should be assessed for a potential concomitant cold-induced form.

Perioperative Anaphylaxis from a Perspective of Temperature

Perioperative anaphylaxis poses a special challenge due to its unique condition with the additive effects of surgery and anesthesia, which tends to be more difficult to recognize, diagnose, and manage, resulting in potentially fatal outcomes. Appropriate prevention and treatment benefits patients and reduces mortality and morbidity. Significant body temperature changes occur during anaphylaxis and/or anesthesia, which correlates with the outcomes. During the perioperative period, body temperature and anaphylaxis bidirectionally interact with each other, and anaphylaxis is generally deteriorated by hypothermia, which is usually required in cardiac surgeries. Perioperative factors, such as surgery and anesthesia, affect body temperature and anaphylaxis. The complicated role of body temperature and its application in the diagnosis of perioperative anaphylaxis and prediction of the outcomes are still unclear. To date, a profile of body temperature change during perioperative anaphylaxis is lacking, which requires further study. This literature review was conducted with updated data on perioperative anaphylaxis from the perspective of temperature as a component aiming to bring attention to and offer some cues for improving perioperative prevention and management for perioperative medical teams.Supplemental data for this article is available online at https://doi.org/10.1080/08941939.2021.1922553 .

Perioperative hypersensitivity reactions during childhood and outcomes of subsequent anesthesia

BACKGROUND

Pediatric perioperative hypersensitivity reactions are rare, and possibly life-threatening. Identification of precise etiology is crucial to circumvent future re-exposures.

AIMS

We aim to evaluate the clinical features and triggers of perioperative hypersensitivity reactions in children, and determine the outcomes of subsequent general anesthesia.

METHODS

A retrospective study was performed with patients who underwent skin testing for general anesthesia between 2007 and 2019. We noted demographic features and skin tests (neuromuscular blocking agents, induction agents, and antibiotics). We also recorded specific immunoglobulin Es or provocation results of drugs or substances (latex, chlorhexidine, and ethylene oxide) that patients were exposed to antecedent to the reaction. Telephone interviews were performed to determine the current status of the participants and reconsider subsequent anesthesia.

RESULTS

We enrolled 50 children (58% male) with a suspected perioperative hypersensitivity reaction. The median age was 6.67 (4.4-11.5) years, and the median time between the reaction, and skin tests was 4 (1-36) months. The most common potential causative agents were neuromuscular blocking agents (n = 8), midazolam (n = 3), ketamine (n = 2), and propofol (n = 1). Three children exhibited hypersensitivity to more than one general anesthetics, and three patients were allergic to latex. Thirty-one patients received subsequent anesthesia, and only one patient had a hypersensitivity reaction. A previous history multiple of general anesthesia administration (≥2) increased the risk of reaction to neuromuscular blocking agents.

CONCLUSION

Data on perioperative hypersensitivity reactions during childhood are rare due to limited diagnostic procedures. Different preference of general anesthetics may change the causative agent. Meticulous evaluation is necessary to safely administer subsequent anesthesia.

Cold urticaria - What we know and what we do not know

Cold urticaria (ColdU) is a common form of chronic inducible urticaria characterized by the development of wheals, angioedema or both in response to cold exposure. Recent research and guideline updates have advanced our understanding and management of ColdU. Today, its pathophysiology is thought to involve the cold-induced formation of autoallergens and IgE to these autoallergens, which provoke a release of proinflammatory mediators from skin mast cells. The classification of ColdU includes typical and atypical subtypes. We know that cold-induced wheals usually develop on rewarming and resolve within an hour and that anaphylaxis can occur. The diagnosis relies on the patient's history and cold stimulation testing. Additional diagnostic work-up, including a search for underlying infections, should only be done if indicated by the patient's history. The management of ColdU includes cold avoidance, the regular use of nonsedating antihistamines and the off-label use of omalizumab. However, many questions regarding ColdU remain unanswered. Here, we review what is known about ColdU, and we present important unanswered questions on the epidemiology, underlying pathomechanisms, clinical heterogeneity and treatment outcomes. Our aim is to guide future efforts that will close these knowledge gaps and advance the management of ColdU.