Approach to Perioperative Anaphylaxis in 2020: Updates in Diagnosis and Management

Kalangara, Jerry P.; Vanijcharoenkarn, Kristine; Lynde, Grant C.; McIntosh, N.; Kuruvilla, Merin

doi:10.1007/s11882-020-00980-y

Cited by 17 publications

(14 citation statements)

References 64 publications

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“…While allergic reactions to opioids are frequently reported, true IgE-mediated hypersensitivity is rare. Only 15% of patients referred for drug provocation testing due to concern with anaphylactic opioid reactions were diagnosed with opioid allergy in one analysis, and opioids are believed to be implicated in less than 2% of all cases of intraoperative anaphylaxis [431,432]. Angioedema and hemodynamic instability are more likely to indicate true hypersensitivity than other reactions [431,433].…”

Section: Postoperative Opioid Considerationsmentioning

confidence: 99%

“…The majority of opioid reactions are not mediated by IgE but by mast cell degranulation, however, and may present as hives, hypotension, urticaria, pruritus, and/or severe anaphylactoid responses. More synthetic opioids exhibit decreasing rates of opioid-mediated histamine release, so should be considered in cases of pseudoallergy [431][432][433][434].…”

Section: Postoperative Opioid Considerationsmentioning

confidence: 99%

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Perioperative Pain Management and Opioid Stewardship: A Practical Guide

et al. 2021

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Surgical procedures are key drivers of pain development and opioid utilization globally. Various organizations have generated guidance on postoperative pain management, enhanced recovery strategies, multimodal analgesic and anesthetic techniques, and postoperative opioid prescribing. Still, comprehensive integration of these recommendations into standard practice at the institutional level remains elusive, and persistent postoperative pain and opioid use pose significant societal burdens. The multitude of guidance publications, many different healthcare providers involved in executing them, evolution of surgical technique, and complexities of perioperative care transitions all represent challenges to process improvement. This review seeks to summarize and integrate key recommendations into a “roadmap” for institutional adoption of perioperative analgesic and opioid optimization strategies. We present a brief review of applicable statistics and definitions as impetus for prioritizing both analgesia and opioid exposure in surgical quality improvement. We then review recommended modalities at each phase of perioperative care. We showcase the value of interprofessional collaboration in implementing and sustaining perioperative performance measures related to pain management and analgesic exposure, including those from the patient perspective. Surgery centers across the globe should adopt an integrated, collaborative approach to the twin goals of optimal pain management and opioid stewardship across the care continuum.

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Section: Postoperative Opioid Considerationsmentioning

confidence: 99%

Section: Postoperative Opioid Considerationsmentioning

confidence: 99%

Perioperative Pain Management and Opioid Stewardship: A Practical Guide

et al. 2021

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“…The evaluation of patients with POA must include a detailed history, comprehensive testing of all medications used in the perioperative period, and recommendation of alternative medications when a causative agent is identified (Carrion et al 2020 ). Allergen testing includes the skin prick test (SPT), intradermal test (IDT), basophil activation test (BAT), specific IgE (sIgE), and others (Kalangara et al 2021 ). Available literature from European and Australian populations suggests that neuromuscular blocking agents (NMBAs) are the most common cause of POA (Mertes et al 2016 ).…”

Section: Introductionmentioning

confidence: 99%

Clinical characteristics and allergen detection of perioperative anaphylaxis: a 12-year retrospective analysis from an anesthesia clinic in China

et al. 2022

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Background Anaphylaxis during anesthesia is a rare but often a potentially life-threatening event for patients. Identifying culprit agents responsible for anaphylaxis is of great important for avoiding potential re-exposure to allergens, but it poses great challenge for anesthetists. This retrospective study aimed to analyze the culprits of patients with a history of perioperative anaphylaxis referred to an anesthesia allergy clinic in China, and to evaluate the role of allergy diagnostic tests in clinical practice. Methods A total of 145 patients (102 female/43 male) who attended the Anesthesia Allergy Clinic for allergen detection between 1 January 2009 and 31 December 2020 were reviewed retrospectively. Clinical characteristics, results of allergy diagnostic tests including skin, and/or basophil activation tests, and the incidence of repeat anaphylaxis after use of recommended alternative anesthetics were obtained. Results Of these 145 patients, 109 patients (75.2%, 74 females/35 males) were determined to experience perioperative anaphylaxis. The most common presenting clinical feature was cardiovascular manifestations (n = 63, 57.8%). According to diagnostic work up, the most common causative agents for perioperative anaphylaxis were neuromuscular blocking agents (n = 35, 32.1%). After diagnostic work up, 52 patients underwent repeat anesthesia. None of these patients experienced recurrent anaphylaxis. Conclusions This study suggests that neuromuscular blocking agents are the main cause of perioperative anaphylaxis. For patients with perioperative anaphylaxis, allergy diagnostic tests are essential to identify causative agents, and to find suitable alternative drugs for the future planning of subsequent anesthetics.

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“…Rocuronium is an intermediate-acting NNMB in amino-steroid structure used in general anesthesia. The allergic reactions associated with this agent have been linked to the quaternary ammonium group included in its structure (3,4).…”

Section: Introductionmentioning

confidence: 99%