Perioperative anaphylaxis in children: A report from the Wake‐Up Safe collaborative

Abstract

Background Anaphylactic reactions to antigens in the perioperative environment are uncommon, but they have a potential to lead to serious morbidity and/or mortality. The incidence of anaphylactic reactions is 1:37 000 pediatric anesthetics, and substantially less than the 1:10 000 to 1:20 000 incidence in the adult population. Neuromuscular blocking agents, latex, and antibiotics are the most frequently cited triggers. To date, there is no comprehensive report on perioperative anaphylactic reactions in children in the United States. Using the Wake‐up Safe database, we examined the incidence and consequences of reported perioperative anaphylaxis events. Methods We reviewed the Wake‐up Safe database from 2010 to 2017 and identified all reported instances of anaphylaxis. The triggering agent, timing, and location of the registered event, severity of patient harm, and preventability were identified. Narrative review of free‐text comments entered by reporting centers was performed to determine presenting symptoms, and interventions required. Type of case was identified from procedure codes provided in mandatory fields. Results Among 2 261 749 cases reported to the Wake‐up Safe database during the study period, perioperative anaphylactic reactions occurred in 1:36 479 (0.003%). Antibiotics, neuromuscular blocking agents, and opioid analgesics were the main triggers. Forty‐nine cases (79%) occurred in the operating room, and 13 cases (21%) occurred in off‐site locations. Seven (11%) patients required cardiopulmonary resuscitation following the onset of symptoms. Thirty‐five (57%) patients were treated with epinephrine or epinephrine plus other medications, whereas 5% were managed only with phenylephrine. Most cases (97%) required escalation of care after the event. Regarding case preventability, 91% of cases were marked as either “likely could not have been prevented” or “almost certainly could not have been prevented.” Conclusion The estimated incidence of anaphylaxis and inciting agents among the pediatric population in this study were consistent with the most recent published studies outside of the United States; however, new findings included need for cardiopulmonary resuscitation in 11% of cases, and estimated fatality of 1.6%. The management of perioperative anaphylaxis could be improved for some cases as epinephrine was not administered, or its administration was delayed. Fewer than half of reported cases had additional investigation to formally identify the responsible agent.

Modified fluid gelatin 4% for perioperative volume replacement in pediatric patients (GPS): Results of a European prospective noninterventional multicenter study

“…24,25 TA B L E 3 Changes in acid-base, electrolyte, and hemoglobin concentrations during infusion of modified fluid gelatin 4% in saline (sal-GEL) or in a balanced electrolyte solution (bal-GEL). The data are presented as mean ± SD (95%CI) Generally, the incidence of perioperative anaphylactic reactions is lower in children (1:37 000) than in adults (1:10 000-1:20 000), 26 and lowest in neonates and infants. 27 Neuromuscular blocking agents, latex, and antibiotics are the most frequently cited triggers.…”

From little adults to pediatric patients: quality improvement in pediatric anesthesia

“…It is based on specific components: (1) 'smart aims' defined in advance as the goal(s) for the program; (2) 'key drivers', that is factors required to support the program (e.g., financial and human resources, knowledge dissemination and institutional leadership support for implementation of QI initiatives) and lastly (3) interventions performed to make the key drivers fully operational. Since its development almost a decade ago, the Wake Up Safe Collaboration has contributed with reports on multiple relations of high importance for the quality in pediatric anesthesia [16][17][18][19]. The latest being a report on perioperative anaphylaxis in children published early in 2021 [19].…”

“…Since its development almost a decade ago, the Wake Up Safe Collaboration has contributed with reports on multiple relations of high importance for the quality in pediatric anesthesia [16][17][18][19]. The latest being a report on perioperative anaphylaxis in children published early in 2021 [19]. Overall, the analysis of reason for and preventability of adverse events is considered a great strength of the Collaboration.…”

Role of sugammadex in the treatment of anaphylaxis due to rocuronium in children: Extrapolation from adult and animal reports

“…The adoption of a latex‐free environment in most countries has eliminated sensitivity to latex and subsequently decreased anaphylaxis to this agent. A review using the Wake‐Up Safe database recently identified antibiotics, neuromuscular blocking agents, chlorhexidine, and dyes used for radiologic imaging as the most common agents responsible for allergic reactions in pediatric‐aged patients 7 . Of the neuromuscular blocking agents, rocuronium and succinylcholine are the most common.…”

“…A review using the Wake-Up Safe database recently identified antibiotics, neuromuscular blocking agents, chlorhexidine, and dyes used for radiologic imaging as the most common agents responsible for allergic reactions in pediatric-aged patients. 7 Of the neuromuscular blocking agents, rocuronium and succinylcholine are the most common. Sugammadex (Bridion ® , Merck & Co.) is a novel pharmacologic agent that received approval for clinical use from the United States Food & Drug Administration (FDA) in December 2015.…”