These guidelines are a consensus document developed by a working party of the Australian and New Zealand Anaesthetic Allergy Group (ANZAAG) to provide an approach to the investigation of perioperative anaphylaxis. They focus primarily on the use of skin testing as it is the investigation with the greatest clinical utility for the identification of the likely causative agent and potentially safer alternatives. The practicalities and process of skin testing, its limitations, and the place of other tests are discussed. These guidelines also address the roles of graded challenge and in vitro testing. The implications of anaphylaxis associated with neuromuscular blocking agents, beta-lactam antibiotics, local anaesthetic agents and chlorhexidine are discussed. Evidence for the recommendations is derived from literature searches using the words skin test, allergy, anaphylaxis, anaesthesia, and each of the individual agents listed in these guidelines. The individual articles were then reviewed for suitability for inclusion in these guidelines. Where evidence was not strong, as is the situation for many perioperative agents, expert consensus from the ANZAAG working party was used. These guidelines are intended for use by specialists involved in the investigation of perioperative allergy. They have been approved following peer review by members of ANZAAG and are available on the ANZAAG website: http://www.anzaag.com/anaphylaxis-management/testing-guidelines.pdf.

ObjectivesCurrent evidence to support non-medical prescribing is predominantly qualitative, with little evaluation of accuracy, safety and appropriateness. Our aim was to evaluate a new model of service for the Australia healthcare system, of inpatient medication prescribing by a pharmacist in an elective surgery preadmission clinic (PAC) against usual care, using an endorsed performance framework.DesignSingle centre, randomised controlled, two-arm trial.SettingElective surgery PAC in a Brisbane-based tertiary hospital.Participants400 adults scheduled for elective surgery were randomised to intervention or control.InterventionA pharmacist generated the inpatient medication chart to reflect the patient's regular medication, made a plan for medication perioperatively and prescribed venous thromboembolism (VTE) prophylaxis. In the control arm, the medication chart was generated by the Resident Medical Officers.Outcome measuresPrimary outcome was frequency of omissions and prescribing errors when compared against the medication history. The clinical significance of omissions was also analysed. Secondary outcome was appropriateness of VTE prophylaxis prescribing.ResultsThere were significantly less unintended omissions of medications: 11 of 887 (1.2%) intervention orders compared with 383 of 1217 (31.5%) control (p<0.001). There were significantly less prescribing errors involving selection of drug, dose or frequency: 2 in 857 (0.2%) intervention orders compared with 51 in 807 (6.3%) control (p<0.001). Orders with at least one component of the prescription missing, incorrect or unclear occurred in 208 of 904 (23%) intervention orders and 445 of 1034 (43%) controls (p<0.001). VTE prophylaxis on admission to the ward was appropriate in 93% of intervention patients and 90% controls (p=0.29).ConclusionsMedication charts in the intervention arm contained fewer clinically significant omissions, and prescribing errors, when compared with controls. There was no difference in appropriateness of VTE prophylaxis on admission between the two groups.Trial RegistrationRegistered with ANZCTR—ACTR Number ACTRN12609000426280

Sugammadex is a selective binding agent for aminosteroid neuromuscular blockers whose use is increasing in anaesthetic practice. We present three cases of severe anaphylaxis coincident with sugammadex administration. Subsequent intradermal testing confirmed sugammadex as the triggering agent, with all patients having positive skin responses to a 1:100 dilution of the standard 100 mg/ml solution and two out of three having a positive response to a 1:1000 dilution. As all patients were administered sugammadex to reverse neuromuscular blockade with rocuronium, we considered that sugammadex-rocuronium complexes were a potential unique allergen. In the two patients who were additionally tested with a rocuronium-sugammadex (3.6:1 molecular ratio) mixture, the wheal-and-flare response was significantly attenuated.

Infrared thermography (IRT) has been used as a non-invasive means of assessing stress responses in animals. Changes in surface temperature that relate to redirected blood flow have been associated with emotional responses in a range of species. For example, when horses were subjected to a sham clipping procedure, increases in eye temperature were found to correlate significantly with increases in salivary cortisol. The Pessoa Training Aid is claimed to enhance the physical development of the horse but may also increase the psychological stress associated with training. The aim of the current study was to use IRT to evaluate whether the use of this training device affected the stress response of horses during a lunge session. Riding school horses (n=8) were used for the study. All had previously been lunged in the Pessoa. Each horse was lunged for two sessions of approximately 15 minutes, once with and once without the Pessoa using a cross-over design. In each session the horse was lunged on both reins at walk, trot, canter, trot and walk. With the Pessoa the horse was lunged initially with the device fitted loosely and it was only tightened for the second trot. Thermal images were taken from a distance of one metre after each gait and from each side of the horse using a Mobir GuidIR M4 thermal camera. Ambient temperature was also recorded. A digital rectal thermometer was used to measure core temperature. Thermal images were analysed using Guide IR analyser software. The same area around the eye, on the neck and around the ear was circled on each image and the maximum temperature recorded. Mean temperatures (eye, ear, neck and core) were calculated for each gait with and without the Pessoa. A two-way repeated measures ANOVA was carried out on the mean temperatures to assess the effects of Pessoa and gait. Significantly higher eye temperatures were recorded with the Pessoa (30.59 ±0.58°C) than without it (28.7±0.83°C) (p<0.05). There was also a significant effect of gait (p<0.01), with the highest eye temperature being recorded following the second trot when the Pessoa was worn (32.34±2.61°C) and the lowest at halt (27.5±0.95°C). There was no significant effect of either gadget or gait on ear or neck temperature. Significantly higher core temperatures were found when the Pessoa was used (with: 37.11±0.2°C; without: 36.7±0.17°C) although this was not affected by gait. No correlation between ambient temperature and eye, ear or neck temperature was found. The results of this preliminary study indicate that the horses experienced more stress when lunged with the Pessoa than without it. The increased eye temperature that occurred in relation to gait and was highest after the second trot was accentuated by the use of the Pessoa following tightening of the device. The use of IRT offers an objective non-invasive method of assessing the horse's response to other training methods and a means of improving the welfare of the ridden horse.