Allergic reactions in anaesthesia: are suspected causes confirmed on subsequent testing?

Krøigaard, Mogens; Garvey, Lene Heise; Menné, Torkil; Husum, B.

doi:10.1093/bja/aei198

Cited by 90 publications

(54 citation statements)

References 10 publications

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“…This reinforces the message conveyed by Kroigaard and colleagues in 2005 [5], who said that an informed guess is not a reliable way of determining the cause of a suspected hypersensitivity reaction, a fact compounded by the high number of different drugs administered in a short period of time during anaesthesia. It is also worrying that 10% of anaesthesia-related immediate hypersensitivity reactions reported to the UK Medicines Control Agency were fatal [43].…”

Section: Discussionsupporting

confidence: 79%

“…A study from 2005 showed that an informed guess was not a reliable way of determining the cause of a suspected hypersensitivity reaction during anaesthesia, and may put a significant number of patients at unnecessary risk [5]. The aims of our service were: to determine the cause of the event; to identify any agent responsible; to determine those drugs which were safe to use in future anaesthetics; and to make recommendations for safe peri-operative care.…”

Section: Introductionmentioning

confidence: 99%

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Anaesthesia-associated hypersensitivity reactions: seven years' data from a British bi-specialty clinic

McEwan

Karanam

et al. 2015

Anaesthesia

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SummaryOur bi-specialty clinic was established to systematically investigate patients with suspected peri-operative hypersensitivity reactions. Four hundred and ten patients were studied; 316 following an intra-operative reaction ('postoperative' group) and 94 with a previous history of reaction, referred before undergoing anaesthesia ('pre-operative' group). In the postoperative group, 173 (54.7%) were diagnosed with IgE-mediated reactions: 65 (37.6%) to neuromuscular blocking drugs; 54 (31.2%) antibiotics; 15 (8.7%) chlorhexidine and 12 (6.9%) patent blue dye. Reactions were severe in 114 patients (65.9%). All reactions to patent blue dye were severe. We identified IgE sensitisation in 22 (13.2%) cases with isolated mucocutaneous reactions. Only 173 (54.7%) patients had serum tryptase samples taken. Referrers' suspected causal agent was confirmed in only 37.2% of patients. Of 94 patients reviewed 'pre-operatively', 29 (30.8%) were diagnosed with IgE-mediated hypersensitivity reactions, reinforcing the importance of investigating this group of patients. Knowledge of the range of causative agents identified in our study should guide the investigation of suspected peri-operative hypersensitivity reactions.

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Section: Discussionsupporting

confidence: 79%

Section: Introductionmentioning

confidence: 99%

Anaesthesia-associated hypersensitivity reactions: seven years' data from a British bi-specialty clinic

McEwan

Karanam

et al. 2015

Anaesthesia

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“…A retrospective survey comparing suspected causes with the result of subsequent testing found that, in 49 of 67 cases, the suspected agent did not match testing results. 9 Tryptase, a protease released from activated mast cells, can be used as a marker of immune activation. An elevated serum tryptase concentration in blood drawn within several hours after the event can be helpful, although it cannot differentiate between anaphylaxis and an anaphylactoid reaction.…”

Section: Discussionmentioning

confidence: 99%

Case report: Fentanyl-associated intraoperative anaphylaxis with pulmonary edema

Cummings

Arnaut

2007

Can J Anesth/J Can Anesth

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Purpose:To describe an atypical presentation of intraoperative anaphylaxis due to fentanyl. Clinical features:A 40-yr-old otherwise healthy woman was admitted for abdominal hysterectomy. She denied any drug allergies or past adverse anesthetic reactions. Physical examination, vital signs, and laboratory findings were all within normal limits. Twenty minutes after induction of general anesthesia with propofol, lidocaine, fentanyl, and rocuronium, she developed sudden onset of hypotension and bronchospasm. She was treated with fluids and epinephrine, but nonetheless required mechanical ventilation for 48 hr. Chest x-ray revealed pulmonary edema which resolved over two days. She recovered completely and was discharged home. Subsequent skin testing showed reactions to fentanyl and succinylcholine. Because the patient had not received succinylcholine, the cause of her anaphylaxis was attributed to fentanyl. The patient later returned for her hysterectomy and tolerated spinal anesthesia with bupivacaine and morphine.

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“…Severe, potentially life-threatening anaphylaxis from simple cutaneous application such as perioperative skin disinfection and wound cleansing remains anecdotal and probably underestimated. In a recent survey, chlorhexidine accounted for 27% of the overlooked perioperative hypersensitivity reactions (171). Note that this prevalence of chlorhexidine anaphylaxis is not observed in other countries.…”

Section: Chlorhexidine and Other Antisepticsmentioning

confidence: 94%

Anaphylaxis during anaesthesia: diagnostic approach

Ebo¹,

Fisher²,

Hagendorens³

et al. 2007

Allergy

193

197

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Anaesthesiologists administer several drugs while providing general anaesthesia. Many of these drugs can elicit adverse drug reactions that fall apart into two major types. First, reactions that are usually dose-dependent and related to the pharmacological properties of the drug and/or its metabolites. Second, reactions that are unrelated to the drug's pharmacological characteristics and that are less dose-dependent. These reactions comprise drug intolerance, idiosyncratic reactions and drug-induced immune-mediated allergic and nonimmune-mediated so-called pseudo-allergic or anaphylactoid reactions. The terms anaphylactic and anaphylactoid, however, have been used inconsistently in the literature. Therefore, the nomenclature task force set up by the European Academy of Allergy and Immunology (EAACI) has proposed that anaphylactic-type reactions should be reclassified into allergic anaphylaxis and nonallergic anaphylaxis. Allergic anaphylaxis being further subdivided in IgE-mediated and non-IgE-mediated reactions (1).The exact prevalence of anaphylaxis during anaesthesia is difficult to ascertain. The estimated overall frequency has been reported to vary between 1 in 3500 and 1 in 13 000 procedures in French series (2, 3) and between 1 in 10 000 and 1 in 20 000 in an Australian study (4). The clinical manifestation of these reactions is not infrequently an almost immediate generalized response with bronchospasm and hypotension. The degree of severity varies and does not allow differentiation between an IgE-mediated or non-IgE mediated reaction resulting from nonspecific mediator release (5). The mortality from these reactions is in the range from 3 to 6%, and an additional 2% of patients experience significant residual brain damage (4).Diagnosis of anaphylaxis during anaesthesia is not always straightforward. It can be hampered as a broad spectrum of different drugs can elicit heterogeneous allergic and nonallergic reactions with distinct and sometimes unclear pathological mechanisms. Problems are certainly compounded as multiple drugs need to be administered during general anaesthesia. In addition, nonanaesthesia related drugs or procedures (e.g. disinfection) are sometimes administered/performed in the perioperative period and can also be the cause of an allergic reaction.In addition, none of the available diagnostic tests demonstrates absolute accuracy. False-positive test 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 di...

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Allergic reactions in anaesthesia: are suspected causes confirmed on subsequent testing?

Cited by 90 publications

References 10 publications

Anaesthesia-associated hypersensitivity reactions: seven years' data from a British bi-specialty clinic

Anaesthesia-associated hypersensitivity reactions: seven years' data from a British bi-specialty clinic

Case report: Fentanyl-associated intraoperative anaphylaxis with pulmonary edema

Anaphylaxis during anaesthesia: diagnostic approach

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