BackgroundThe incidence of anaphylaxis might be increasing. Data for fatal anaphylaxis are limited because of the rarity of this outcome.ObjectiveWe sought to document trends in anaphylaxis admissions and fatalities by age, sex, and cause in England and Wales over a 20-year period.MethodsWe extracted data from national databases that record hospital admissions and fatalities caused by anaphylaxis in England and Wales (1992-2012) and crosschecked fatalities against a prospective fatal anaphylaxis registry. We examined time trends and age distribution for fatal anaphylaxis caused by food, drugs, and insect stings.ResultsHospital admissions from all-cause anaphylaxis increased by 615% over the time period studied, but annual fatality rates remained stable at 0.047 cases (95% CI, 0.042-0.052 cases) per 100,000 population. Admission and fatality rates for drug- and insect sting–induced anaphylaxis were highest in the group aged 60 years and older. In contrast, admissions because of food-triggered anaphylaxis were most common in young people, with a marked peak in the incidence of fatal food reactions during the second and third decades of life. These findings are not explained by age-related differences in rates of hospitalization.ConclusionsHospitalizations for anaphylaxis increased between 1992 and 2012, but the incidence of fatal anaphylaxis did not. This might be due to increasing awareness of the diagnosis, shifting patterns of behavior in patients and health care providers, or both. The age distribution of fatal anaphylaxis varies significantly according to the nature of the eliciting agent, which suggests a specific vulnerability to severe outcomes from food-induced allergic reactions in the second and third decades.

Bone cement implantation syndrome (BCIS) is poorly understood. It is an important cause of intraoperative mortality and morbidity in patients undergoing cemented hip arthroplasty and may also be seen in the postoperative period in a milder form causing hypoxia and confusion. Hip arthroplasty is becoming more common in an ageing population. The older patient may have co-existing pathologies which can increase the likelihood of developing BCIS. This article reviews the definition, incidence, clinical features, risk factors, aetiology, pathophysiology, risk reduction, and management of BCIS. It is possible to identify high risk groups of patients in which avoidable morbidity and mortality may be minimized by surgical selection for uncemented arthroplasty. Invasive anaesthetic monitoring should be considered during cemented arthroplasty in high risk patients.

The overall incidence of perioperative anaphylaxis was estimated to be 1 in 10 000 anaesthetics.

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Management of perioperative anaphylaxis could be improved, especially with respect to administration of epinephrine, cardiac compressions, and i.v. fluid. Sequelae were common.

The methods of NAP6 were robust in identifying causative agents of anaphylaxis, and support the accompanying analytical papers.

SummaryWe report the occurrence of an epidural haematoma after the removal of a lumbar epidural catheter, which had been inserted 2 days previously for surgery to revise a thrombosed femoralpopliteal graft. Pre-operatively the patient received intravenous heparin by infusion, but this was stopped 7 h prior to epidural insertion. Coagulation studies were normal. The epidural catheter insertion was unremarkable. Postoperatively, the patient received a continuous epidural infusion of fentanyl (3 mg.ml À1 ) and bupivacaine (0.0625%), in addition to systemic anticoagulant therapy with heparin. On the second postoperative day, the patient was noted to have developed bilateral leg weakness (following transfer to another department for Doppler studies). The epidural catheter was inadvertently removed while the patient was anticoagulated and paraparesis developed overnight. After a significant delay, an epidural haematoma was diagnosed and treated by decompressive laminectomy. At operation an epidural haematoma extending posteriorly from T 12 to L 3 was removed.Keywords Anaesthetic techniques, regional; epidural. Surgery; vascular. Complications; epidural haematoma. ...................................................................................... Correspondence to: Dr R. W. H. Skilton Accepted: 12 February 1998 Spinal bleeding resulting in permanent paraplegia is a 'worst case' scenario following epidural catheter insertion. Although the incidence of epidural bleeding may be as high as 10% following catheter placement, the incidence of significant spinal bleeding (paraplegia requiring laminectomy) has been estimated at 1: 1000 000 [1] in patients without clinically apparent coagulation disorders. Only 61 cases of epidural haematoma associated with regional anaesthesia were reported in the world literature up to 1993, with 32 involving the use of an epidural catheter [2]. We report a further case and discuss the aetiological factors involved. Case historyA 75-year-old, 78-kg male was transferred from a private hospital for further management of his ischaemic right leg. Three months previously he had surgery to repeat coronary artery bypass grafts following an episode of unstable angina and congestive cardiac failure. He had a markedly dilated left ventricle with an ejection fraction of 15% and had required an intra-aortic balloon pump to allow weaning from cardiopulmonary bypass. The balloon pump had been inserted into the right femoral artery and the right leg was noted to be cool and mottled in the recovery room. The balloon pump was removed and a femoral embolectomy performed with some improvement. This was followed 2 months later by a femoral-distal bypass procedure but this had to be revised due to thrombosis. A further thrombosis of the new superficial femoral artery graft resolved after treatment with urokinase and systemic heparinisation. However, the peroneal supply remained impaired and he developed ischaemic ulceration on his foot. The patient was transferred to our tertiary centre for evaluation a...