Acute Management, Diagnosis, and Follow-Up of Suspected Perioperative Hypersensitivity Reactions in Flanders 2001-2018

Abstract

Background: Despite numerous efforts to describe the clinical manifestations and the epidemiology of perioperative hypersensitivity (POH), there remains room to increase awareness among anesthetists and immunologists/allergists.Objective: To report the findings of a 17-year survey of suspected POH in Antwerp (Belgium).Methods: We analyzed clinical and diagnostic data from 715 patients referred because of a suspected POH reaction, between January 1, 2001 and May 31, 2018. 456 patients demonstrating a POH could be queried about subsequent anesthesia.Results: 608 cases formed the final dataset; 208 had a non-life-threatening reaction, 400 a lifethreatening reaction. In life-threatening reactions, hypotension was predominating. In the non-lifethreatening reactions, 83.9% of the patients displayed cutaneous manifestations. In life-threatening reactions, intravenous adrenaline and fluids were administered in respectively 75.7% and 31%, and 41.3% had their intervention abandoned. Mast cell activation (MCA) was mainly, but not exclusively, observed in severe grades but did not predict the mechanistic process nor the culprit. A cause was identified in 77.8% of severe and 48.6% of milder cases. Main culprits are neuromuscular blocking agents, latex, cefazolin and dyes. 156 had uneventful anesthesia, except one patient who was inadvertently re-exposed to hidden chlorhexidine.Conclusions: This study highlights that there is room for an improved acute management and an optimized diagnostic work-up that should not be restricted to patients with severe reactions and/or showing mast cell activation.

IgE‐mediated chlorhexidine allergy—Cross‐reactivity with other biguanide disinfectants

“…While such reactions are still rare, they are the elicitor in up to 10% of perioperative anaphylaxis in Denmark and Belgium. 5,6 The route of sensitization to CHX, either IgE or T cells specific, is still unclear. CHX represents a bipolar compound with two chloroguanide endings linked by a hexamethylene bridge (Figure 1).…”

“…Exposure to CHX‐containing devices (eg, in central venous catheters, Arrow®) or CHX‐coated urethral gels (eg, Instillagel®, Chlorhexidine Gluconate Solution; Farco‐Pharma GmbH) may even result in anaphylaxis and anaphylactic shock. While such reactions are still rare, they are the elicitor in up to 10% of perioperative anaphylaxis in Denmark and Belgium 5,6 …”

Advances and novel developments in drug hypersensitivity diagnosis

“…A recent study of perioperative hypersensitivity showed that high tryptase values were detected more frequently in life‐threatening reactions than in non‐life‐threatening ones. Furthermore, mast cell activation determined using the formula tryptase > 1.2 × baseline‐tryptase + 2 µg/L was more frequent in life‐threatening reactions and in adults compared with children 64,65 …”

“…Furthermore, mast cell activation determined using the formula tryptase > 1.2 × baseline-tryptase + 2 µg/L was more frequent in life-threatening reactions and in adults compared with children. 64,65 Histamine is the most abundant and important inflammatory mediator for acute anaphylaxis, with plasma sensitivity ranging from 61%-92% and specificity from 51%-91%. 62 However, it is difficult to assess due to its short half-life in serum (20 minutes).…”

What do we know about perioperative hypersensitivity reactions and what can we do to improve perioperative safety?

“…Hypersensitivity reactions to latex exposure have been reported to occur more frequently in childhood. In the adult population, hypersensitivity reactions were more common in women approximately 40 years of age and in men over 50 years of age [ 9 , 15 , 16 , 18 , 22 , 31 , 38 , 56 ]. An increased risk in mastocytosis, asthma, hypertension, coronary artery disease, obesity and morbid obesity, especially with the use of angiotensin-converting enzyme inhibitors and beta-blockers, was also reported [ 7 , 8 , 55 ].…”