An EAACI position paper on the investigation of perioperative immediate hypersensitivity reactions

Abstract

Perioperative immediate hypersensitivity reactions are rare. Subsequent allergy investigation is complicated by multiple simultaneous drug exposures, the use of drugs with potent effects and the many differential diagnoses to hypersensitivity in the perioperative setting. The approach to the investigation of these complex reactions is not standardized, and it is becoming increasingly apparent that collaboration between experts in the field of allergy/immunology/dermatology and anaesthesiology is needed to provide the best possible care for these patients. The EAACI task force behind this position paper has therefore combined the expertise of allergists, immunologists and anaesthesiologists. The aims of this position paper were to provide recommendations for the investigation of immediate-type perioperative hypersensitivity reactions and to provide practical information that can assist clinicians in planning and carrying out investigations. | 1873GARVEY Et Al.

Management of suspected immediate perioperative allergic reactions: an international overview and consensus recommendations

“…A task force of the drug allergy interest group of the European Academy of Allergy and Clinical Immunology has published a position paper with recommendations for investigation of perioperative allergic reactions. 8 Lastly, the Australian and New Zealand Anaesthetic Allergy Group has published testing and management guidelines. 9,10 In both countries, investigation is primarily undertaken by anaesthesiologists with varying degrees of allergist involvement.…”

“…The clinical picture can mimic allergic reactions and be interpreted as such, and this may only be disproved when subsequent allergy investigation is negative. 8,43 Fig 1 summarises possible mechanisms underlying a clinical picture suggestive of an immediate perioperative allergic reaction, including symptoms unrelated to allergy, but related to effects of drugs or surgical/anaesthetic management. The most important mechanism to identify is the specific activation of the immune system or allergic reactions mediated by specific IgE antibodies towards the culprit agents. IgEmediated reactions account for 50e60% of cases and carry the risk of more severe reactions on re-exposure than non-IgEmediated reactions.…”

“…If symptoms arise from a single organ system and serum tryptase measured at the time of the reaction is not elevated when compared with the patient's own baseline sample obtained after the reaction, an allergic reaction is less likely, and further investigation may not always be necessary (Table 2). 8,43 Hypotension, as a single symptom, can have multiple causes (e.g. result from the pharmacological effects of drugs, major bleeding or other types of shock).…”

“…All Grade IIeIV reactions and Grade I reactions with generalised urticaria, erythema, or both should be referred for allergy investigation. 8 Ideally, investigations should take place in specialised clinics with collaboration between anaesthesiologists and allergists with experience in perioperative allergy investigation. 8,10 However, this is not available in many countries.…”

Progress in understanding hypersensitivity reactions to nonsteroidal anti‐inflammatory drugs

“…4 NSAIDs are the main elicitors of drug hypersensitivity reactions (DHRs). [5][6][7] NSAIDs hypersensitivity among general population is frequent (0.5%-5.7%), overcoming antibiotics allergy in some studies. 5,8,9 However, in high-risk populations it increases: up to 20% in asthmatics with nasal polyps (NPs) and to 30% in chronic spontaneous urticaria (CSU) patients.…”