Perioperative Anaphylaxis
Section snippets
Epidemiology
General anesthesia is a unique situation described as a reversible state of unconsciousness, amnesia, analgesia, and immobility as a result of administering several drugs in a short period.1 Many of these drugs can elicit adverse reactions either related to their pharmacologic properties and usually dose dependent, or unrelated to the pharmacologic properties and less dose dependent. The latter reactions comprise drug intolerance, idiosyncratic reactions, and anaphylactic reactions, which can
Mechanism
Allergic anaphylaxis is most commonly caused by the interaction of an allergen with specific immunoglobulin E (IgE) antibodies. These antibodies, in sensitized individuals, bind to high-affinity FcɛRI receptors located in the plasma membrane of tissue mast cells and blood basophils, and to low-affinity FcɛRII receptors on lymphocytes, eosinophils, and platelets. This interaction stimulates the cells to release preformed and newly synthesized inflammatory mediators, such as histamine, tryptase,
Investigation of an allergic reaction
Any suspected hypersensitivity reaction during anesthesia must be extensively investigated using combined peri- and postoperative testing. It is important to confirm the nature of the reaction, to identify the responsible drug, to detect possible cross-reactivity in cases of anaphylaxis to a neuromuscular blocking agent (NMBA), and to provide recommendations for future anesthetic procedures.24, 25 Serious attempts have been made to standardize and validate in vitro and in vivo techniques for
Causal agents
The overall distribution of the various causal agents incriminated in allergic anaphylaxis during anesthesia is similar in most reported series. Every agent used during the perioperative period may be involved. NMBAs represent the most frequently incriminated substances ranging from 50% to 70%, followed by latex (12%–16.7%) and antibiotics (15%) (Table 4). Dyes, hypnotic agents, local anesthetics, opioids, colloids, aprotinin, protamine, chlorhexidine, or nonsteroidal antiinflammatory drugs
Aspirin and other NSAIDs
With the increase in consumption of NSAIDs used in multimodal postoperative analgesia,124 these are likely to be among the most common drugs inducing hypersensitivity reactions. Bronchospasms, urticaria, angioedema, and anaphylaxis from these drugs are most often of a nonimmunologic nature, and result from inhibition of the cyclooxygenase 1 (COX-1) isoenzyme with subsequent depletion of prostaglandin E2 and unrestrained synthesis of cysteinyl leukotrienes, and release of mediators from mast
Risk factors for perioperative anaphylaxis
Allergy to anesthetic agents is the first factor to consider. Any unexplained life-threatening reaction during a previous anesthesia might be an allergic reaction and is a major risk factor for a renewed reaction if the responsible drug is readministered.16 Ideally, all patients having experienced an episode of perioperative anaphylaxis would have undergone complete allergoanesthetic follow-up before further anesthetics. The practical reality is different. In addition, in many countries, the
Treatment
There is a wide array of reaction severity and responsiveness to treatment. In addition, no controlled trials of treatment in human beings are available. As a result, the ultimate judgment with regards to a particular clinical procedure or treatment scheme must be made by the clinician in light of the clinical presentation and available diagnostic and treatment options.140 During anesthesia, the patient is usually monitored and has intravenous access, which gives the optimum conditions for
Summary
Perioperative anaphylaxis is a significant adverse event during anesthesia. It remains underestimated because it is underreported. NMBAs, latex, and antibiotics are the most frequently incriminated drugs, although other drugs used during the perioperative period might be involved. Because no premedication can effectively prevent an allergic reaction, any suspected hypersensitivity reaction must be extensively investigated using combined peri- and postoperative testing. Patients must be fully
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Cited by (121)
Clinical variables and genetic variants associated with perioperative anaphylaxis in Chinese Han population: A pilot study
2024, World Allergy Organization JournalSevere perioperative anaphylaxis: Incidence in a tertiary hospital in Spain over a 20-year period. A historical cohort study
2023, Revista Espanola de Anestesiologia y ReanimacionUpdates in the Management of Perioperative Vasoplegic Syndrome
2022, Advances in AnesthesiaCitation Excerpt :Epinephrine is often required for the treatment of severe reactions [79]. Given the increase in NO production, MB has been posited to specifically treat the VS associated with anaphylaxis and may be helpful, although current data is extrapolated only from case reports [77,79]. Animal studies have suggested that an epinephrine-MB treatment combination may be more effective than epinephrine alone [80].
Perioperative Anaphylaxis
2022, Immunology and Allergy Clinics of North America