Perioperative Anaphylaxis

https://doi.org/10.1016/j.mcna.2010.04.002Get rights and content

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

First page preview

First page preview
Click to open first page preview

References (155)

  • M.M. Fisher et al.

    Mast cell tryptase in anaesthetic anaphylactoid reactions

    Br J Anaesth

    (1998)
  • B.A. Baldo et al.

    Anaphylaxis to muscle relaxant drugs: cross-reactivity and molecular basis of binding of IgE antibodies detected by radioimmunoassay

    Mol Immunol

    (1983)
  • L. Guilloux et al.

    A new radioimmunoassay using a commercially available solid support for the detection of IgE antibodies against muscle relaxants

    J Allergy Clin Immunol

    (1992)
  • J.L. Gueant et al.

    Non-specific cross-reactivity of hydrophobic serum IgE to hydrophobic drugs

    Mol Immunol

    (1995)
  • M.M. Fisher et al.

    Failure to prevent an anaphylactic reaction to a second neuromuscular blocking drug during anaesthesia

    Br J Anaesth

    (1999)
  • J.H. Levy et al.

    Weal and flare responses to intradermal rocuronium and cisatracurium in humans

    Br J Anaesth

    (2000)
  • F. Leynadier et al.

    Prick tests in the diagnosis of anaphylaxis to general anaesthetics

    Br J Anaesth

    (1987)
  • M.M. Fisher et al.

    Intradermal compared with prick testing in the diagnosis of anaesthetic allergy

    Br J Anaesth

    (1997)
  • P.M. Mertes et al.

    Anaphylaxis to dyes during the perioperative period: reports of 14 clinical cases

    J Allergy Clin Immunol

    (2008)
  • N. Bermejo et al.

    Platelet serotonin is a mediator potentially involved in anaphylactic reaction to neuromuscular blocking drugs

    Br J Anaesth

    (1993)
  • N. Abuaf et al.

    Validation of a flow cytometric assay detecting in vitro basophil activation for the diagnosis of muscle relaxant allergy

    J Allergy Clin Immunol

    (1999)
  • M. Rose et al.

    Rocuronium: high risk for anaphylaxis?

    Br J Anaesth

    (2001)
  • E. Florvaag et al.

    The pholcodine story

    Immunol Allergy Clin North Am

    (2009)
  • J.O. Hourihane et al.

    Impact of repeated surgical procedures on the incidence and prevalence of latex allergy: a prospective study of 1263 children

    J Pediatr

    (2002)
  • Y. Ishizawa

    Mechanisms of anesthetic actions and the brain

    J Anesth

    (2007)
  • S.G. Johansson et al.

    A revised nomenclature for allergy. An EAACI position statement from the EAACI nomenclature task force

    Allergy

    (2001)
  • M.M. Fisher et al.

    The epidemiology and clinical features of anaphylactic reactions in anaesthesia

    Anaesth Intensive Care

    (1981)
  • M.C. Laxenaire

    Ann Fr Anesth Reanim

    (2002)
  • P.M. Mertes et al.

    Allergic reactions occurring during anaesthesia

    Eur J Anaesthesiol

    (2002)
  • J. Watkins

    Adverse anaesthetic reactions. An update from a proposed national reporting and advisory service

    Anaesthesia

    (1985)
  • S. Thienthong et al.

    The Thai Anesthesia Incidents Study (THAI Study) of perioperative allergic reactions

    J Med Assoc Thai

    (2005)
  • F. Escolano et al.

    Rev Esp Anestesiol Reanim

    (2002)
  • T. Harboe et al.

    Anaphylaxis during anesthesia in Norway: a 6-year single-center follow-up study

    Anesthesiology

    (2005)
  • M. Fisher et al.

    Anaphylaxis during anaesthesia: current aspects of diagnosis and prevention

    Eur J Anaesthesiol

    (1994)
  • P.M. Mertes et al.

    Anaphylactic and anaphylactoid reactions occurring during anesthesia in France in 1999–2000

    Anesthesiology

    (2003)
  • H. Mitsuhata et al.

    The epidemiology and clinical features of anaphylactic and anaphylactoid reactions in the perioperative period in Japan

    Masui

    (1992)
  • K.P. Light et al.

    Adverse effects of neuromuscular blocking agents based on yellow card reporting in the U.K.: are there differences between males and females?

    Pharmacoepidemiol Drug Saf

    (2006)
  • H. Hedin et al.

    Pathomechanisms of dextran-induced anaphylactoid/anaphylactic reactions in man

    Int Arch Allergy Appl Immunol

    (1982)
  • J. Moss

    Muscle relaxants and histamine release

    Acta Anaesthesiol Scand Suppl

    (1995)
  • E.H. Jooste et al.

    Rapacuronium augments acetylcholine-induced bronchoconstriction via positive allosteric interactions at the M3 muscarinic receptor

    Anesthesiology

    (2005)
  • P.M. Mertes et al.

    Hypersensitivity reactions to neuromuscular blocking agents

    Curr Pharm Des

    (2008)
  • P.M. Mertes et al.

    Reducing the risk of anaphylaxis during anaesthesia: guidelines for clinical practice

    J Investig Allergol Clin Immunol

    (2005)
  • M. Kroigaard et al.

    Scandinavian Clinical Practice Guidelines on the diagnosis, management and follow-up of anaphylaxis during anaesthesia

    Acta Anaesthesiol Scand

    (2007)
  • P.M. Mertes et al.

    Skin reactions to intradermal neuromuscular blocking agent injections: a randomized multicenter trial in healthy volunteers

    Anesthesiology

    (2007)
  • M.M. Fisher

    The preoperative detection of risk of anaphylaxis during anaesthesia

    Anaesth Intensive Care

    (2007)
  • D.G. Ebo et al.

    Basophil activation test by flow cytometry: present and future applications in allergology

    Cytometry B Clin Cytom

    (2008)
  • A.B. Guttormsen et al.

    No consumption of IgE antibody in serum during allergic drug anaphylaxis

    Allergy

    (2007)
  • P.M. Mertes et al.

    Allergy and anaphylaxis in anaesthesia

    Minerva Anestesiol

    (2004)
  • A. Baumann et al.

    Refractory anaphylactic cardiac arrest after succinylcholine administration

    Anesth Analg

    (2009)
  • J.M. Malinovsky et al.

    Systematic follow-up increases incidence of anaphylaxis during adverse reactions in anesthetized patients

    Acta Anaesthesiol Scand

    (2008)
  • Cited by (121)

    • Updates in the Management of Perioperative Vasoplegic Syndrome

      2022, Advances in Anesthesia
      Citation 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
    View all citing articles on Scopus
    View full text