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Management of perioperative anaphylaxis: Systematic review. INTERNATIONAL JOURNAL OF SURGERY OPEN 2023. [DOI: 10.1016/j.ijso.2023.100595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
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Iwakiri M, Inoue R, Uchida K. Allergic reactions to propofol in adult patients with egg or soybean allergy: a retrospective cohort study from a large database of a single institute. JA Clin Rep 2023; 9:1. [PMID: 36617591 PMCID: PMC9826766 DOI: 10.1186/s40981-022-00591-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 12/17/2022] [Accepted: 12/21/2022] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND In recent years, many reports have indicated that propofol is safe to administer to patients with egg/soybean allergy in Western countries. Egg allergy is more frequent in Asia, but there are limited reports regarding allergic reactions to propofol use among adults. This study aimed to determine whether propofol causes allergic reactions in patients with egg/soybean allergy. METHODS Adult patients who underwent surgery involving anesthesiologists from 2018 to 2021 were included. In all patients, we reviewed food allergy information in their electronic medical record and extracted anesthetics. Patients with egg/soybean allergy were subdivided into two groups on the basis of intraoperative use of propofol. We evaluated each group for allergic reactions within 24 h after the induction of anesthesia. The primary outcome was a relative risk of allergic reactions after propofol use for patients with egg/soybean allergy. RESULTS In total, 22,111 patients with 28,710 anesthesia records were identified. Among patients with egg/soybean allergy, 173 (0.8%) patients and 237 (0.8%) anesthesia records were included in the study. Among the records of egg-/soybean-allergic patients, 151 were administered propofol, and 86 were not. The relative risk of allergic reactions after propofol use for patients with egg/soybean allergy was 1.14 (95% confidence interval, 0.10-12.4; p = 0.74). CONCLUSION The use of propofol in patients with egg/soybean allergy does not significantly increase the relative risk of allergic reactions. Therefore, anesthesiologists can appropriately determine the indication for propofol, even in patients with egg/soybean allergy. TRIAL REGISTRATION UMIN-CTN, UMIN000049321 registered 26 October 2022 - retrospectively registered, https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000056167.
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Affiliation(s)
- Masaki Iwakiri
- grid.412708.80000 0004 1764 7572Department of Anesthesiology and Pain Relief Center, The University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655 Japan
| | - Reo Inoue
- grid.412708.80000 0004 1764 7572Department of Anesthesiology and Pain Relief Center, The University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655 Japan
| | - Kanji Uchida
- grid.412708.80000 0004 1764 7572Department of Anesthesiology and Pain Relief Center, The University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655 Japan
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Ramírez CE, Domingo MV, Font AP, Esteller PG, Marchuet MJC, Foix MPS, Sanchez JCM, García MM. Do cross-food allergies to propofol exist? Anesth Pain Med (Seoul) 2022; 17:381-385. [PMID: 36317430 PMCID: PMC9663949 DOI: 10.17085/apm.22195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 08/24/2022] [Accepted: 08/25/2022] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND Propofol is a short and rapidly acting intravenous anesthetic extensively used for the induction and maintenance of general anesthesia. It is a lipid emulsion that contains soybean oil, purified egg phosphatide, and egg lecithin. Therefore, the package leaflet indicates that its administration is contraindicated in patients allergic to soy, eggs, or peanuts. Our study aimed to determine whether patients with proven food allergies are allergic to propofol. METHODS Patients of all ages allergic to soy, eggs, or peanuts who agreed to undergo skin testing for propofol allergies were included. The subjects first underwent a skin test to confirm food allergies. If candidates were negative, they were excluded. If the result was positive, a propofol skin test was performed. RESULTS Sixty-four patients with confirmed food allergies underwent a propofol skin test. Only one was positive in the propofol skin test (1.6%). The patient was allergic to peanuts and soybeans. These results reinforce the idea that there is no justification for avoiding propofol use in these subjects. CONCLUSIONS Propofol can be safely administered to patients allergic to soy, eggs, or peanuts. We recommend caution in patients with a history of anaphylaxis after ingestion of the above-mentioned foods.
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Affiliation(s)
- Carles Espinós Ramírez
- Department of Anesthesiology, Consorci Sanitari de Terrassa, Terrassa, Spain
- International University of Catalonia, Barcelona, Spain
| | - Marta Viñas Domingo
- Department of Anesthesiology, Consorci Sanitari de Terrassa, Terrassa, Spain
| | - Anna Peig Font
- Department of Anesthesiology, Consorci Sanitari de Terrassa, Terrassa, Spain
- International University of Catalonia, Barcelona, Spain
| | - Paula Gil Esteller
- Department of Anesthesiology, Consorci Sanitari de Terrassa, Terrassa, Spain
- International University of Catalonia, Barcelona, Spain
| | | | | | | | - Maria Martinez García
- Department of Anesthesiology, Consorci Sanitari de Terrassa, Terrassa, Spain
- International University of Catalonia, Barcelona, Spain
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Pradhan U, Oofuvong M, Karnjanawanichkul O, Pakpirom J. Risk predictive tools of perioperative drug hypersensitivity reaction: A case-control study. PLoS One 2022; 17:e0262362. [PMID: 35025954 PMCID: PMC8758003 DOI: 10.1371/journal.pone.0262362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 12/21/2021] [Indexed: 11/19/2022] Open
Abstract
Objective We aimed to determine the risk factors of perioperative drug hypersensitivity reaction (DHR) and develop a predictive score for use in clinical practice. Methods A case-control study was conducted in patients who underwent anesthesia at a tertiary hospital in Thailand, between 2015–2018. DHR cases were graded clinically from 1 to 4 according to the World Federation of Societies of Anesthesiologists by two anesthesiologists. Controls were randomly matched with cases (ratio 2:1) by age group and month and type of surgery. Patient and anesthesia-related factors and agents given intraoperatively were recorded. A risk score was derived from the coefficients of the significant predictors of the final multivariate logistic regression model. Risk scores, adjusted odds ratios (OR) for perioperative DHR and 95% confidence intervals (CI) were determined. Results Overall, 325 cases and 650 controls were recruited. The severity of DHR was grade 1 (72.9%), grade 2 (24%), and grade 3 (3.1%). Our risk predictive tools for perioperative DHR provided a sensitivity of 62% and specificity of 65%. Predictive scores of subgroups of moderate to severe DHR showed high specificity (80%) but low sensitivity (47%). Common predictors of overall DHR and moderate to severe DHR were history of drug allergy to 2 or more drug categories (score 2.5–3.5), being allergic to analgesics (score 2.5–4.0), and intraoperative morphine use (score of 1). The sole predictor of high-risk perioperative DHR (score ≥3.5) was airway management with an endotracheal tube intubation (OR 5.6, 95% CI 2.2–14.4) whereas history of allergic rhinitis (OR 11.7, 95% CI 1.3–105.1) was a predictor of high-risk moderate to severe DHR (score ≥2.5). Conclusions Our predictive tool for perioperative DHR provided a modest predictive ability. History of drug allergies, rhinitis, morphine use and endotracheal intubation were significant risk factors of DHR after adjusting for age and type of surgery.
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Affiliation(s)
- Ujal Pradhan
- Faculty of Medicine, Department of Anesthesiology, Prince of Songkla University, Hat Yai, Thailand
| | - Maliwan Oofuvong
- Faculty of Medicine, Department of Anesthesiology, Prince of Songkla University, Hat Yai, Thailand
- * E-mail:
| | - Orarat Karnjanawanichkul
- Faculty of Medicine, Department of Anesthesiology, Prince of Songkla University, Hat Yai, Thailand
| | - Jatuporn Pakpirom
- Faculty of Medicine, Department of Anesthesiology, Prince of Songkla University, Hat Yai, Thailand
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Abstract
Perioperative anaphylaxis is a potentially life-threatening and under-recognized event most commonly caused by antibiotics, neuromuscular blocking agents, dyes, latex, and disinfectants. This review provides updates in the epidemiology and pathogenesis of perioperative anaphylaxis, discusses culprit agents, and highlights the tenets of management including a comprehensive allergy evaluation.
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Affiliation(s)
- Mitchell M Pitlick
- Division of Allergic Diseases, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, USA.
| | - Gerald W Volcheck
- Division of Allergic Diseases, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, USA
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Broyles AD, Banerji A, Barmettler S, Biggs CM, Blumenthal K, Brennan PJ, Breslow RG, Brockow K, Buchheit KM, Cahill KN, Cernadas J, Chiriac AM, Crestani E, Demoly P, Dewachter P, Dilley M, Farmer JR, Foer D, Fried AJ, Garon SL, Giannetti MP, Hepner DL, Hong DI, Hsu JT, Kothari PH, Kyin T, Lax T, Lee MJ, Lee-Sarwar K, Liu A, Logsdon S, Louisias M, MacGinnitie A, Maciag M, Minnicozzi S, Norton AE, Otani IM, Park M, Patil S, Phillips EJ, Picard M, Platt CD, Rachid R, Rodriguez T, Romano A, Stone CA, Torres MJ, Verdú M, Wang AL, Wickner P, Wolfson AR, Wong JT, Yee C, Zhou J, Castells M. Practical Guidance for the Evaluation and Management of Drug Hypersensitivity: Specific Drugs. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 8:S16-S116. [PMID: 33039007 DOI: 10.1016/j.jaip.2020.08.006] [Citation(s) in RCA: 89] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 08/10/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Ana Dioun Broyles
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Aleena Banerji
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Sara Barmettler
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Catherine M Biggs
- Department of Pediatrics, British Columbia Children's Hospital, University of British Columbia, Vancouver, Canada
| | - Kimberly Blumenthal
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Patrick J Brennan
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Rebecca G Breslow
- Division of Sports Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein, School of Medicine, Technical University of Munich, Munich, Germany
| | - Kathleen M Buchheit
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Katherine N Cahill
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Josefina Cernadas
- Allergology and Immunology Service, Centro Hospitalar Universitário de S.João Hospital, Porto, Portugal
| | - Anca Mirela Chiriac
- Division of Allergy, Department of Pulmonology, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, France
| | - Elena Crestani
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Pascal Demoly
- Division of Allergy, Department of Pulmonology, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, France
| | - Pascale Dewachter
- Department of Anesthesiology and Intensive Care Medicine, Groupe Hospitalier Paris-Seine-Saint-Denis, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Meredith Dilley
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Jocelyn R Farmer
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Dinah Foer
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Ari J Fried
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Sarah L Garon
- Associated Allergists and Asthma Specialists, Chicago, Ill
| | - Matthew P Giannetti
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - David L Hepner
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Mass
| | - David I Hong
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Joyce T Hsu
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Parul H Kothari
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Timothy Kyin
- Division of Asthma, Allergy & Immunology, University of Virginia, Charlottesville, Va
| | - Timothy Lax
- Division of Allergy and Inflammation, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Min Jung Lee
- Allergy and Immunology at Hoag Medical Group, Newport Beach, Calif
| | - Kathleen Lee-Sarwar
- Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Anne Liu
- Division of Allergy / Immunology, Stanford University School of Medicine, Palo Alto, Calif
| | - Stephanie Logsdon
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Margee Louisias
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Andrew MacGinnitie
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Michelle Maciag
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Samantha Minnicozzi
- Division of Allergy and Clinical Immunology, Respiratory Medicine, Department of Pediatrics, University of Virginia, Charlottesville, Va
| | - Allison E Norton
- Division of Allergy, Immunology and Pulmonology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tenn
| | - Iris M Otani
- Division of Pulmonary, Critical Care, Allergy, and Sleep, Department of Medicine, University of California, San Francisco Medical Center, San Francisco, Calif
| | - Miguel Park
- Division of Allergic Diseases, Mayo Clinic, Rochester, Minn
| | - Sarita Patil
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Elizabeth J Phillips
- Department of Medicine & Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tenn
| | - Matthieu Picard
- Division of Allergy and Clinical Immunology, Department of Medicine, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Québec, Canada
| | - Craig D Platt
- Division of Immunology, Boston Children's Hospital, Boston, Mass
| | - Rima Rachid
- Division of Immunology, Boston Children's Hospital, Boston, Mass
| | - Tito Rodriguez
- Drug Allergy Department, Al-Rashed Allergy Center, Sulaibikhat, Al-Kuwait, Kuwait
| | - Antonino Romano
- IRCCS Oasi Maria S.S., Troina, Italy & Fondazione Mediterranea G.B. Morgagni, Catania, Italy
| | - Cosby A Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Maria Jose Torres
- Allergy Unit and Research Group, Hospital Regional Universitario de Málaga, UMA-IBIMA-BIONAND, ARADyAL, Málaga, Spain
| | - Miriam Verdú
- Allergy Unit, Hospital Universitario de Ceuta, Ceuta, Spain
| | - Alberta L Wang
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Paige Wickner
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Anna R Wolfson
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Johnson T Wong
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Christina Yee
- Division of Immunology, Boston Children's Hospital, Boston, Mass
| | - Joseph Zhou
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Mariana Castells
- Drug hypersensitivity and Desensitization Center, Brigham and Women's Hospital, Boston, Mass
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Recurrent anaphylaxis to a gelatin-based colloid plasma substitute and to cetuximab following sensitisation to galactose-alpha-1,3-galactose. Br J Anaesth 2021; 126:e200-e202. [PMID: 33810867 DOI: 10.1016/j.bja.2021.02.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 02/02/2021] [Accepted: 02/19/2021] [Indexed: 11/21/2022] Open
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Insights into hypersensitivity reactions in dentistry. Porto Biomed J 2020. [DOI: 10.1097/j.pbj.0000000000000090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Solé D, Spindola MAC, Aun MV, Araújo Azi LMTD, Bernd LAG, Garcia DB, Capelo AV, Cumino DDO, Lacerda AE, Lima LC, Morato EF, Nunes RR, Rubini NDPM, da Silva J, Tardelli MA, Watanabe AS, Curi EF, Sano F. [Update on perioperative hypersensitivity reactions: joint document from the Brazilian Society of Anesthesiology (SBA) and Brazilian Association of Allergy and Immunology (ASBAI) - Part II: etiology and diagnosis]. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2020; 70:642-661. [PMID: 33308829 PMCID: PMC9373683 DOI: 10.1016/j.bjan.2020.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 07/19/2020] [Accepted: 08/11/2020] [Indexed: 11/30/2022]
Abstract
This second joint document, written by experts from the Brazilian Association of Allergy and Immunology (ASBAI) and Brazilian Society of Anesthesiology (SBA) concerned with perioperative anaphylaxis, aims to review the pathophysiological reaction mechanisms, triggering agents (in adults and children), and the approach for diagnosis during and after an episode of anaphylaxis. As anaphylaxis assessment is extensive, the identification of medications, antiseptics and other substances used at each setting, the comprehensive data documentation, and the use of standardized nomenclature are key points for obtaining more consistent epidemiological information on perioperative anaphylaxis.
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Affiliation(s)
- Dirceu Solé
- Associação Brasileira de Alergia e Imunologia, São Paulo, SP, Brazil; Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo, SP, Brazil
| | - Maria Anita Costa Spindola
- Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brazil; Universidade Federal de Santa Catarina, Hospital Universitário Professor Polydoro Ernani de São Thiago, Florianópolis, SC, Brazil
| | - Marcelo Vivolo Aun
- Associação Brasileira de Alergia e Imunologia, São Paulo, SP, Brazil; Faculdade Israelita de Ciências da Saúde Albert Einstein, São Paulo, SP, Brazil; Universidade de São Paulo, Faculdade de Medicina, Hospital Universitário, São Paulo, SP, Brazil
| | - Liana Maria Tôrres de Araújo Azi
- Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brazil; Universidade Federal da Bahia, Hospital Universitário Professor Edgard Santos, Salvador, BA, Brasil.
| | - Luiz Antonio Guerra Bernd
- Associação Brasileira de Alergia e Imunologia, São Paulo, SP, Brazil; Fundação Faculdade Federal de Ciências Médicas de Porto Alegre, Porto Alegre, RS, Brazil
| | - Daniela Bianchi Garcia
- Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brazil; Hospital Infantil Pequeno Príncipe, Curitiba, PR, Brasil
| | - Albertina Varandas Capelo
- Associação Brasileira de Alergia e Imunologia, São Paulo, SP, Brazil; Universidade Federal do Rio de Janeiro, Hospital Universitário Gaffrée e Guinle, Rio de Janeiro, RJ, Brazil
| | - Débora de Oliveira Cumino
- Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brazil; Hospital Infantil Sabará, São Paulo, SP, Brazil
| | - Alex Eustáquio Lacerda
- Associação Brasileira de Alergia e Imunologia, São Paulo, SP, Brazil; Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo, SP, Brazil
| | - Luciana Cavalcanti Lima
- Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brazil; Instituto Medicina Integral Prrofessor Fernando Figueira, Recife, PE, Brazil
| | - Edelton Flávio Morato
- Universidade Federal de Santa Catarina, Hospital Universitário Professor Polydoro Ernani de São Thiago, Florianópolis, SC, Brazil
| | - Rogean Rodrigues Nunes
- Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brazil; Hospital Geral de Fortaleza (HGF), Departamento de Anestesia, Fortaleza, CE, Brazil
| | - Norma de Paula Motta Rubini
- Associação Brasileira de Alergia e Imunologia, São Paulo, SP, Brazil; Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Jane da Silva
- Associação Brasileira de Alergia e Imunologia, São Paulo, SP, Brazil; Universidade Federal de Santa Catarina, Hospital Universitário Professor Polydoro Ernani de São Thiago, Florianópolis, SC, Brazil
| | - Maria Angela Tardelli
- Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo, SP, Brazil; Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brazil
| | - Alexandra Sayuri Watanabe
- Associação Brasileira de Alergia e Imunologia, São Paulo, SP, Brazil; Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, São Paulo, SP, Brazil
| | - Erick Freitas Curi
- Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brazil; Universidade Federal do Espírito Santo, Vitória, ES, Brasil
| | - Flavio Sano
- Associação Brasileira de Alergia e Imunologia, São Paulo, SP, Brazil; Hospital Nipo Brasileiro, São Paulo, SP, Brasil
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Update on perioperative hypersensitivity reactions: joint document from the Brazilian Society of Anesthesiology (SBA) and Brazilian Association of Allergy and Immunology (ASBAI) - Part II: etiology and diagnosis. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2020. [PMID: 33308829 PMCID: PMC9373683 DOI: 10.1016/j.bjane.2020.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
This second joint document, written by experts from the Brazilian Association of Allergy and Immunology (ASBAI) and Brazilian Society of Anesthesiology (SBA) concerned with perioperative anaphylaxis, aims to review the pathophysiological reaction mechanisms, triggering agents (in adults and children), and the approach for diagnosis during and after an episode of anaphylaxis. As anaphylaxis assessment is extensive, the identification of medications, antiseptics and other substances used at each setting, the comprehensive data documentation, and the use of standardized nomenclature are key points for obtaining more consistent epidemiological information on perioperative anaphylaxis.
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Practical Guidance for the Evaluation and Management of Drug Hypersensitivity: General Concepts. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:S3-S15. [PMID: 32791249 DOI: 10.1016/j.jaip.2020.08.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 08/07/2020] [Indexed: 01/19/2023]
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12
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Patil SS, Sun L, Fox CJ, Anthony KE, Anzalone FA, Fisher PM, Girma B, Huang GJ, Barsley EL, Cornett EM, Urman RD, Kaye AD. Multiple drug allergies: Recommendations for perioperative management. Best Pract Res Clin Anaesthesiol 2020; 34:325-344. [PMID: 32711838 DOI: 10.1016/j.bpa.2020.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 05/20/2020] [Indexed: 02/06/2023]
Abstract
Life-threatening hypersensitivity reactions are more likely to occur in patients with a history of allergy, atopy, or asthma. Hence, in a patient who presented with a history of multiple drug allergies (MDA), an allergological assessment should be performed prior to surgical procedure. Drug allergies, being one of the causes of catastrophic events occurring in the perioperative period, are of major concern to anesthesiologists. Neuromuscular blocking agents are regularly used during anesthesia and are one of the most common causes of perioperative anaphylaxis. They are estimated to be responsible for 50%-70% of perioperative hypersensitivity reactions. Antibiotics and latex represent the next two groups of drug allergy. Allergic reactions to propofol are rare with an incidence of 1:60,000 exposures. Although intraoperative drug anaphylaxis is rare, it contributes to 4.3% of deaths occurring during general anesthesia. These recommendations discuss pathophysiology of MDA, preoperative evaluation, and anesthesia considerations as well as the prevention and management of allergic reactions in anesthetized patients with a history of MDA.
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Affiliation(s)
- Shilpadevi S Patil
- Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA, 71103, USA.
| | - Lu Sun
- School of Medicine, LSU Health Sciences Center New Orleans, 2020 Gravier Street, New Orleans, LA, 70112, USA.
| | - Charles J Fox
- Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA, 71103, USA.
| | | | - Fallon A Anzalone
- LSU Health Sciences Center New Orleans, 433 Bolivar Street, New Orleans, LA, 70112, USA.
| | - Paul M Fisher
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Brook Girma
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Genkai J Huang
- Division of Family Medicine, HCA Houston Healthcare West, 12141 Richmond Ave. Houston, TX, 77082, USA.
| | - Emily L Barsley
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Elyse M Cornett
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA.
| | - Alan D Kaye
- Departments of Anesthesiology and Pharmacology, Toxicology, and Neurosciences, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA.
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Abstract
In a series of articles dealing with hypnotics for induction of anesthesia, this article describes the development and current value of propofol. Its significance far exceeds that of a pure induction hypnotic (sedation in diagnostic and therapeutic procedures and on the intensive care unit). Propofol is also used for sedation in diagnostic and therapeutic procedures and on the intensive care unit. In the field of induction of anesthesia, the alternatives are barely used. Some contraindications are still controversial whereas others are no longer sufficiently anchored in the users' awareness (widespread off-label use). Adverse effects, such as injection pain, infection risk and propofol-related infusion syndrome (PRIS) could be significantly reduced by pharmacovigilance. With appropriate caution nearly the whole spectrum of anesthesiology patients can be treated using propofol. The hemodynamic side effects and the rare but potentially fatal PRIS are limitations. Further developments address the water solubility and the solubilizing agents of propofol.
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Affiliation(s)
- D Bolkenius
- Klinik für Anästhesiologie und Operative Intensivmedizin, Klinikum Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland.
| | - C Dumps
- Klinik für Anästhesiologie und Operative Intensivmedizin, Klinikum Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland
| | - E Halbeck
- Klinik für Anästhesiologie und Operative Intensivmedizin, Klinikum Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland
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14
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Sommerfield DL, Lucas M, Schilling A, Drake-Brockman TFE, Sommerfield A, Arnold A, von Ungern-Sternberg BS. Propofol use in children with allergies to egg, peanut, soybean or other legumes. Anaesthesia 2019; 74:1252-1259. [PMID: 31077340 DOI: 10.1111/anae.14693] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2019] [Indexed: 12/13/2022]
Abstract
Propofol is the most commonly administered intravenous agent for anaesthesia in children. However, there are concerns that the emulsified preparation may not be safe in children with an allergy to egg, peanut, soybean or other legumes. We conducted a retrospective study of children with immunologically confirmed egg, peanut, soybean or legume allergy and who underwent general anaesthesia at Princess Margaret Hospital for Children between 2005 and 2015. We extracted details regarding allergy diagnosis, each anaesthetic administered and any adverse events or signs of an allergic reaction in the peri-operative period. A convenience sample of patients without any known food allergies was identified from our prospective anaesthesia research database and acted as a control group. We identified 304 food-allergic children and 649 procedures where propofol was administered. Of these, 201 (66%) had an egg allergy, 226 (74%) had a peanut allergy, 28 (9%) had a soybean allergy and 12 (4%) had a legume allergy. These were compared with 892 allergy-free patients who were exposed to propofol. In 10 (3%) allergy patients and 124 (14%) allergy-free patients, criteria for a possible allergic reaction were met. In nine of the food-allergic children and in all the controls valid non-allergic explanations for the clinical symptoms were found. One likely mild allergic reaction was experienced by a child with a previous history of intralipid allergy. We conclude that genuine serious allergic reaction to propofol is rare and is not reliably predicted by a history of food allergy.
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Affiliation(s)
- D L Sommerfield
- Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, WA, Australia
- Medical School, The University of Western Australia, Perth, WA, Australia
| | - M Lucas
- Medical School, The University of Western Australia, Perth, WA, Australia
- Department of Paediatric Clinical Immunology, Perth Children's Hospital, Perth, WA, Australia
| | - A Schilling
- Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, WA, Australia
- Medical School, The University of Western Australia, Perth, WA, Australia
| | - T F E Drake-Brockman
- Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, WA, Australia
- Medical School, The University of Western Australia, Perth, WA, Australia
| | - A Sommerfield
- Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, WA, Australia
- Telethon Kids Institute, Perth, WA, Australia
| | - A Arnold
- Department of Paediatric Clinical Immunology, Perth Children's Hospital, Perth, WA, Australia
| | - B S von Ungern-Sternberg
- Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, WA, Australia
- Medical School, The University of Western Australia, Perth, WA, Australia
- Telethon Kids Institute, Perth, WA, Australia
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15
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Risk factors and prevention for perioperative anaphylaxis: a nested case-control study. Int J Clin Pharm 2019; 41:1442-1450. [DOI: 10.1007/s11096-019-00902-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 09/05/2019] [Indexed: 02/07/2023]
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16
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Stepanovic B, Sommerfield D, Lucas M, von Ungern-Sternberg BS. An update on allergy and anaphylaxis in pediatric anesthesia. Paediatr Anaesth 2019; 29:892-900. [PMID: 31379063 DOI: 10.1111/pan.13703] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 07/07/2019] [Accepted: 07/09/2019] [Indexed: 01/31/2023]
Abstract
Childhood allergy is common, and increasing. Many children are incorrectly labeled as having allergy or adverse drug reactions. This can pose a dilemma for anesthetists and lead to a change in practice or drug selection. We review the pathophysiology of hypersensitivity reactions and the implications for anesthesia of food allergy, atopy, and family history of allergy in children. The epidemiology of anaphylaxis is discussed. We discuss the common triggers of perioperative anaphylaxis in children and explore emerging triggers including chlorhexidine and sugammadex. Accurate data on pediatric perioperative anaphylaxis is limited worldwide, with marked geographic variation. This highlights the need for accurate local, district and/or nationwide incident reporting. The clinical features, diagnosis, and management of anaphylaxis under anesthesia are discussed. We review the process of expert allergy testing following a suspected case of anaphylaxis to guide future safe anesthesia administration. The preoperative consultation is an opportunity for referral for allergy testing to allow de-labeling. This has the potential for improved antibiotic stewardship and more effective treatment with first-line therapeutic agents.
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Affiliation(s)
- Bojana Stepanovic
- Department of Anaesthesia and Pain Medicine, Perth Children's Hospital, Perth, Western Australia, Australia
| | - David Sommerfield
- Department of Anaesthesia and Pain Medicine, Perth Children's Hospital, Perth, Western Australia, Australia.,Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Michaela Lucas
- Medical School, The University of Western Australia, Perth, Western Australia, Australia.,Department of Immunology, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Britta S von Ungern-Sternberg
- Department of Anaesthesia and Pain Medicine, Perth Children's Hospital, Perth, Western Australia, Australia.,Medical School, The University of Western Australia, Perth, Western Australia, Australia.,Telethon Kids Institute, Perth, Western Australia, Australia
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17
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Volcheck GW, Hepner DL. Identification and Management of Perioperative Anaphylaxis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:2134-2142. [DOI: 10.1016/j.jaip.2019.05.033] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 05/15/2019] [Accepted: 05/17/2019] [Indexed: 01/07/2023]
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18
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Garvey LH, Dewachter P, Hepner DL, Mertes PM, Voltolini S, Clarke R, Cooke P, Garcez T, Guttormsen AB, Ebo DG, Hopkins PM, Khan DA, Kopac P, Krøigaard M, Laguna JJ, Marshall S, Platt P, Rose M, Sabato V, Sadleir P, Savic L, Savic S, Scherer K, Takazawa T, Volcheck GW, Kolawole H. Management of suspected immediate perioperative allergic reactions: an international overview and consensus recommendations. Br J Anaesth 2019; 123:e50-e64. [DOI: 10.1016/j.bja.2019.04.044] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 04/04/2019] [Accepted: 04/14/2019] [Indexed: 12/11/2022] Open
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19
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Anaesthetic management of patients with pre-existing allergic conditions: a narrative review. Br J Anaesth 2019; 123:e65-e81. [PMID: 30916009 DOI: 10.1016/j.bja.2019.01.020] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 01/12/2019] [Accepted: 01/22/2019] [Indexed: 12/18/2022] Open
Abstract
This narrative review seeks to distinguish the clinical patterns of pre-existing allergic conditions from other confounding non-allergic clinical entities, and to identify the potential related risks and facilitate their perioperative management. Follow-up investigation should be performed after a perioperative immediate hypersensitivity to establish a diagnosis and provide advice for subsequent anaesthetics, the main risk factor for perioperative immunoglobulin E (IgE)-mediated anaphylaxis being a previous uninvestigated perioperative immediate hypersensitivity reaction. The concept of cross-reactivity between drugs used in the perioperative setting and food is often quoted, but usually not supported by evidence. There is no reason to avoid propofol in egg, soy, or peanut allergy. The allergenic determinants have been characterised for fish, shellfish, and povidone iodine, but remain unknown for iodinated contrast agents. Iodinated drugs may be used in seafood allergy. Evidence supporting the risk for protamine allergy in fish allergy and in neutral protamine Hagedorn insulin use is lacking. Conversely, cross-reactivity to gelatin-based colloid may occur in α-gal syndrome. Atopy and allergic asthma along with other non-allergic conditions, such as NSAID-exacerbated respiratory disease, chronic urticaria, mastocytosis, and hereditary or acquired angioedema, are not risk factors for IgE-mediated drug allergy, but there is a perioperative risk associated with the potential for exacerbation of the various conditions.
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20
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Dewachter P, Chollet-Martin S, Mouton-Faivre C, de Chaisemartin L, Nicaise-Roland P. Comparison of Basophil Activation Test and Skin Testing Performances in NMBA Allergy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:1681-1689. [DOI: 10.1016/j.jaip.2017.12.037] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Revised: 11/28/2017] [Accepted: 12/27/2017] [Indexed: 12/31/2022]
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21
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Abstract
The pharmacological and historical knowledge about the currently available intravenous induction hypnotics form the basis for the daily work of anesthetists. Side effects of using hypnotic induction agents must be anticipated and adequately treated. Decades of experience with using intravenous induction hypnotics have led to theoretical requirements for an ideal narcotic agent with a best possible side effect profile. In the absence of this optimal hypnotic induction agent, a careful selection of one or a combination of narcotic drugs is necessary to meet the needs of the respective risk constellation of the patient. While propofol enjoyed increasing frequency of use over the last three decades and is currently regarded as the gold standard in numerous clinics, thiopental is a noteworthy alternative apart from its elimination kinetics. Furthermore, substances with favorable hemodynamic profiles are available with etomidate and ketamine. Midazolam as a short-acting benzodiazepine rounds off the spectrum.
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Affiliation(s)
- C Dumps
- Klinik für Anästhesiologie und Operative Intensivmedizin, Klinikum Augsburg, Stenglinstr. 2, 85156, Augsburg, Deutschland.
| | - D Bolkenius
- Klinik für Anästhesiologie und Operative Intensivmedizin, Klinikum Augsburg, Stenglinstr. 2, 85156, Augsburg, Deutschland
| | - E Halbeck
- Klinik für Anästhesiologie und Operative Intensivmedizin, Klinikum Augsburg, Stenglinstr. 2, 85156, Augsburg, Deutschland
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22
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ALGUNOS MITOS EN ANESTESIOLOGÍA. REVISTA MÉDICA CLÍNICA LAS CONDES 2017. [DOI: 10.1016/j.rmclc.2017.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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23
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Krohne TU, Allam JP, Novak N, Holz FG. ["Iodine allergy" : A medical myth with risks for the ophthalmological patient]. Ophthalmologe 2017; 113:1023-1028. [PMID: 27601148 DOI: 10.1007/s00347-016-0359-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Preoperative disinfection with povidone-iodine results in a significant reduction of the risk for postoperative endophthalmitis and secondary irreversible vision loss in intraocular surgeries and intravitreal injections. Nevertheless, this important measure is often omitted if so-called "iodine allergy" is suspected. We analyze the physiological and allergological basis for the construct of "iodine allergy". METHODS This article is based on a selective literature review using the search term "allergy" in combination with "iodine", "povidone", "indocyanine green", or "seafood". RESULTS Iodine is a chemical element and an essential component of the human body. Scientific proof for the existence of an antibody-mediated allergic reaction (type I reaction) and in particular an immunoglobulin (Ig) E‑mediated anaphylaxis against iodine is lacking. Chemical irritations and contact allergies (type IV reaction) induced by iodine-containing disinfectants are not antibody-mediated and do not cause anaphylaxis (type I reaction). The uncommon antibody-mediated allergies against iodine-containing disinfectants, fluorescent dyes, radiocontrast media, or seafood are not directed against the contained iodine itself but against other components of the respective formulation. Thus, allergic cross-reactivities between these different substance groups are not to be expected. CONCLUSION So-called "iodine allergy" is a medical myth lacking a scientific basis and should not result in increased patient risks due to omitted preoperative disinfection.
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Affiliation(s)
- T U Krohne
- Universitäts-Augenklinik Bonn, Ernst-Abbe-Str. 2, 53127, Bonn, Deutschland.
| | - J-P Allam
- Klinik und Poliklinik für Dermatologie und Allergologie, Universität Bonn, Bonn, Deutschland
| | - N Novak
- Klinik und Poliklinik für Dermatologie und Allergologie, Universität Bonn, Bonn, Deutschland
| | - F G Holz
- Universitäts-Augenklinik Bonn, Ernst-Abbe-Str. 2, 53127, Bonn, Deutschland
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24
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Hsu Blatman KS, Hepner DL. Current Knowledge and Management of Hypersensitivity to Perioperative Drugs and Radiocontrast Media. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:587-592. [DOI: 10.1016/j.jaip.2017.03.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 02/16/2017] [Accepted: 03/21/2017] [Indexed: 12/25/2022]
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25
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Yakarıca Ergen G, Erdogan H, Dilek Sirinoğlu F, Oba S, Cetinkaya F. Knowledge and experience regarding perioperative anaphylaxis among anesthesiologists in Istanbul. AIMS ALLERGY AND IMMUNOLOGY 2017. [DOI: 10.3934/allergy.2017.3.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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26
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Asserhøj LL, Mosbech H, Krøigaard M, Garvey LH. No evidence for contraindications to the use of propofol in adults allergic to egg, soy or peanut†. Br J Anaesth 2016; 116:77-82. [PMID: 26675952 DOI: 10.1093/bja/aev360] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Propofol is thought to be a potential cause of allergic reactions in patients allergic to egg, soy or peanut, since current formulations contain an emulsion that includes egg lecithin and soybean oil. However, other than six case reports lacking in confirmatory evidence of an allergic reaction, there is no evidence linking the two types of allergies. The aim of this study was to examine the frequency of propofol allergy and to investigate if patients with specific immunoglobulin E (IgE) to egg, soy or peanut tolerated propofol. METHODS Study A examined the frequency of propofol allergy in 273 patients systematically investigated for suspected perioperative allergic reactions. Of these, 153 had been exposed to propofol and underwent skin tests and intravenous provocation. Study B retrospectively investigated propofol exposure and tolerance in 520 adult patients with a positive specific IgE to egg, soy or peanut. RESULTS Four of the 153 propofol-exposed patients (2.6%) investigated in study A were diagnosed with propofol allergy. Of these, three tested positive only on intravenous provocation. None of the four had allergic symptoms when eating egg, soy or peanut and none had detectable levels of specific IgE to egg or soy in their serum. In study B we found no signs of allergic reactions towards propofol in 171 retrieved anaesthetic charts from 99 patients with specific IgE to egg, soy or peanut. CONCLUSION No connection between allergy to propofol and allergy to egg, soy or peanut was found. The present practice of choosing alternatives to propofol in patients with this kind of food allergy is not evidence based and should be reconsidered.
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Affiliation(s)
- L L Asserhøj
- Danish Anaesthesia Allergy Centre (DAAC), Allergy Clinic UA-816, Copenhagen University Hospital, Gentofte, Kildegårdsvej 28, 2900 Hellerup, Denmark
| | - H Mosbech
- Danish Anaesthesia Allergy Centre (DAAC), Allergy Clinic UA-816, Copenhagen University Hospital, Gentofte, Kildegårdsvej 28, 2900 Hellerup, Denmark
| | - M Krøigaard
- Danish Anaesthesia Allergy Centre (DAAC), Allergy Clinic UA-816, Copenhagen University Hospital, Gentofte, Kildegårdsvej 28, 2900 Hellerup, Denmark
| | - L H Garvey
- Danish Anaesthesia Allergy Centre (DAAC), Allergy Clinic UA-816, Copenhagen University Hospital, Gentofte, Kildegårdsvej 28, 2900 Hellerup, Denmark
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27
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Abstract
Perioperative anaphylaxis is a unique condition as a result of the additive cardiovascular effects of anesthetics on the cardiovascular disturbances of anaphylaxis. It occurs mainly in adulthood, primarily follows anesthetic induction, and for the most part, is an IgE-mediated pathomechanism. Neuromuscular blocking agents (NMBAs) and antibiotics are the main culprit drugs, while latex is now infrequently involved. The Ring and Messmer scale is a useful tool for demonstrating the clinical severity of perioperative immediate hypersensitivity and guiding its management. Grades III and IV are life-threatening and are referred to as anaphylaxis. Three different clinical patterns of grade III may be observed, where cardiovascular collapse is the cardinal sign. Grade IV presents as cardiac arrest. The initial diagnosis is presumptive, whereas the etiological assessment is linked to the clinical presentation, tryptase levels, and skin test results. Since anaphylaxis presents with significant hypovolemia and vasoplegia, aggressive fluid therapy and epinephrine are the cornerstones of management. Whenever possible, anesthetic discontinuation is also recommended. Scientific evidence in favor of preemptive therapeutic strategies to prevent anaphylaxis in the operative setting is lacking.
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28
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Hakimoğlu S, Tuzcu K, Davarcı I, Karcıoğlu M, Kurt R, Dikey İ. Intraoperative Ephedrine Allergy in a Patient Who Received Chemotherapy and Perioperative Hypersensitivity Reactions. Turk J Anaesthesiol Reanim 2015; 43:130-3. [PMID: 27366482 DOI: 10.5152/tjar.2014.77044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Accepted: 06/04/2014] [Indexed: 11/22/2022] Open
Abstract
Anaesthesia represents a specific set-up in respect to pharmacology, and during this time, early hypersensitivity reactions or anaphylaxis may occur in patients who are exposed to a great number of foreign substances. Intravenous ephedrine (5 mg) was applied to a 37-year-old patient due to the development of intraoperative hypotension in a total abdominal hysterectomy operation. After application, hyperaemia was seen in the track of the intravenous catheter of that extremity. Approximately 15 minutes later, urticarial plaques were observed extensively in the abdomen and in both extremities. Methylprednisolone (100 mg+100 mg) and pheniramine (45.5 mg) were given with an increasing infusion rate of intravenous crystalloid. The patient was extubated without any problem and removed to the recovery unit for observation. After the total disappearance of lesions at postoperative 60 minutes and because of the stability of vital signs, the patient was removed to the service. In the follow-up of surgery, no complication developed, and the patient was discharged on postoperative day 2.
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Affiliation(s)
- Sedat Hakimoğlu
- Department of Anaesthesiology and Reanimation, Mustafa Kemal University Faculty of Medicine, Hatay, Turkey
| | - Kasım Tuzcu
- Department of Anaesthesiology and Reanimation, Mustafa Kemal University Faculty of Medicine, Hatay, Turkey
| | - Işıl Davarcı
- Department of Anaesthesiology and Reanimation, Mustafa Kemal University Faculty of Medicine, Hatay, Turkey
| | - Murat Karcıoğlu
- Department of Anaesthesiology and Reanimation, Mustafa Kemal University Faculty of Medicine, Hatay, Turkey
| | - Raziye Kurt
- Department of Gynecology and Obstetrics, Mustafa Kemal University Faculty of Medicine, Hatay, Turkey
| | - İsmail Dikey
- Department of Anaesthesiology and Reanimation, Mustafa Kemal University Faculty of Medicine, Hatay, Turkey
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29
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López JM, Jiménez BM, Carballada F. [Anaphylaxis in the preanesthesia evaluation]. ACTA ACUST UNITED AC 2015; 62:540-1. [PMID: 25746379 DOI: 10.1016/j.redar.2015.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Revised: 01/21/2015] [Accepted: 01/23/2015] [Indexed: 10/23/2022]
Affiliation(s)
- J M López
- Servicio de Anestesiología y Reanimación, Hospital Universitario Lucus Augusti, Lugo, España.
| | - B M Jiménez
- Servicio de Anestesiología y Reanimación, Hospital Universitario Lucus Augusti, Lugo, España
| | - F Carballada
- Servicio de Alergología, Hospital Universitario Lucus Augusti, Lugo, España
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30
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Abstract
Abstract
Background:
Previously reported incidences for intraoperative hypersensitivity reactions vary more than 15-fold. The goal was to determine the incidence of intraoperative hypersensitivity events at a U.S. surgical center.
Methods:
With institutional review board (Cleveland, Ohio) approval and waiver of written/informed consent, the anesthesia records of adult patients undergoing noncardiac surgery from 2005 to 2011 at the Cleveland Clinic were queried using a novel electronic search protocol developed to identify potential hypersensitivity reactions: cardiovascular collapse defined as systolic arterial blood pressure less than 50 mmHg; administration of epinephrine; administration of diphenhydramine; physician comments in the anesthesia record suggestive of hypersensitivity reactions; laboratory tests for histamine, tryptase, or immunoglobulin-E within 24 h of surgery; and International Classification of Diseases, Ninth Revision, codes suggestive of hypersensitivity reactions. Each electronically identified candidate chart was evaluated by an adjudication committee. Hypersensitivity reactions were graded on a 5-point severity scale. From these data, the authors determined the proportion of operations having adjudicated hypersensitivity reactions, and calculated the 95% exact binomial CI.
Results:
Among 178,746 records, 4,008 charts were identified by the search strategies. After adjudication, 264 hypersensitivity cases were identified. The overall incidence of hypersensitivity reactions was 1:677 surgeries, corresponding to 15 (95% CI, 13 to 17) cases per 10,000 operations. The incidence of severe hypersensitivity reactions (grades 3 to 5) was 1:4,583, corresponding to 2 (95% CI, 2 to 3) cases per 10,000 operations.
Conclusions:
The incidence of severe hypersensitivity reactions was similar to previous reports. However, the overall incidence of hypersensitivity reactions was much greater than reported elsewhere, possibly because of a comprehensive search strategy.
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31
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Perioperative anaphylactic reactions: Review and procedure protocol in paediatrics. Allergol Immunopathol (Madr) 2015; 43:203-14. [PMID: 24231150 DOI: 10.1016/j.aller.2013.07.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Accepted: 07/20/2013] [Indexed: 11/21/2022]
Abstract
Perioperative anaphylactic reactions are immediate, hypersensitive reactions that are potentially life-threatening resulting from a sudden release of mediators from mast cells and basophiles, due to either immune (IgE or non-IgE mediated) or non-immune mechanisms. The most frequent causing agents are neuromuscular blocking agents (NMBAs), latex and antibiotics, with latex being the first cause in paediatrics. With regard to perioperative anaphylactic reactions, the usual early signs and symptoms of an anaphylactic reaction could be overlooked or erroneously interpreted and non-severe anaphylaxis could go undetected, with a risk of more severe reactions in the future. Using the data registered on the anaesthesia sheet, it is essential to establish a chronological relationship between drugs and/or substances administered and the reaction observed. An elevated level of tryptase confirms an anaphylactic reaction, but this does not usually increase in the absence of compromised circulation. An allergy study should be carried out preferably between 4 and 6 weeks after the reaction, using a combination of specific IgE, skin and controlled exposure tests (if indicated). Test sensitivity is good for NMBAs, latex, antibiotics, chlorhexidine, gelatine and povidone, and poor for barbiturates, opiates (these can give false positives since they are histamine releasers) and benzodiazepines. Special preventive measures should be taken, especially in the case of latex. We present the maximum concentrations recommended for skin tests, the recommended dosage to treat anaphylactic reactions in paediatrics and a procedure algorithm for the allergological study of these reactions.
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32
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Kannan JA, Bernstein JA. Perioperative anaphylaxis: diagnosis, evaluation, and management. Immunol Allergy Clin North Am 2015; 35:321-34. [PMID: 25841554 DOI: 10.1016/j.iac.2015.01.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Perioperative anaphylaxis can occur during or after surgery and can have life-threatening consequences. As anesthesia protocols become more complex and incorporate multiple agents to regulate physiologic processes intraoperatively, perioperative anaphylaxis is becoming increasingly recognized. The allergist should obtain detailed records from the anesthesiologist in order to perform appropriate testing to identify the likely causative agents. Testing should ideally be performed 4 to 6 weeks after the reaction to account for a refractory period after mast cell activation. This article includes 2 cases of perioperative anaphylaxis and reviews the historical elements that must be considered after a reaction has occurred.
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Affiliation(s)
- Jennifer A Kannan
- Division of Immunology, Allergy and Rheumatology, Department of Medicine, University of Cincinnati College of Medicine, 3255 Eden Avenue, Suite 350, ML 563, Cincinnati, OH 45267-0563, USA
| | - Jonathan A Bernstein
- Division of Immunology, Allergy and Rheumatology, Department of Medicine, University of Cincinnati College of Medicine, 3255 Eden Avenue, Suite 350, ML 563, Cincinnati, OH 45267-0563, USA; Bernstein Clinical Research Center, 8444 Winton Road, Cincinnati, OH 45231, USA.
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33
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Kulkarni SJ, Kelkar VP, Nayak PP. Anesthesia in a patient with multiple allergies. J Anaesthesiol Clin Pharmacol 2014; 30:433-4. [PMID: 25190964 PMCID: PMC4152696 DOI: 10.4103/0970-9185.137291] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Affiliation(s)
- Sanhita J Kulkarni
- Department of Anaesthesia, Mahatma Gandhi Mission's Medical College and Hospital, Aurangabad, Maharashtra, India
| | - Vasanti P Kelkar
- Department of Anaesthesia, Mahatma Gandhi Mission's Medical College and Hospital, Aurangabad, Maharashtra, India
| | - Prabha P Nayak
- Department of Anaesthesia, Mahatma Gandhi Mission's Medical College and Hospital, Aurangabad, Maharashtra, India
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Abstract
Perioperative anaphylaxis is a life-threatening condition with an estimated prevalence of 1:3,500 to 1:20,000 procedures and a mortality rate of up to 9 %. Clinical presentation involves signs such as skin rash, urticaria, angioedema, bronchospasm, tachycardia, bradycardia, and hypotension. Prompt recognition and treatment is of utmost importance to the patient's prognosis, since clinical deterioration can develop rapidly. Epinephrine is the main treatment drug, and its use should not be postponed, since delayed administration is associated with increased mortality. Elevated levels of serum tryptase help to confirm the diagnosis. The main agents involved in IgE-mediated perioperative anaphylaxis are neuromuscular blocking agents, latex, antibiotics, hypnotics, opioids, and colloids. Specific investigation should be conducted 4 to 6 weeks after the reaction and relies on skin tests, serum-specific IgE, and challenge procedures. This review aims to discuss the main aspects of perioperative anaphylaxis: risk factors, diagnosis, treatment, culprit agents, specific investigation, and preventive measures.
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Molina-Infante J, Arias A, Vara-Brenes D, Prados-Manzano R, Gonzalez-Cervera J, Alvarado-Arenas M, Lucendo AJ. Propofol administration is safe in adult eosinophilic esophagitis patients sensitized to egg, soy, or peanut. Allergy 2014; 69:388-94. [PMID: 24447028 DOI: 10.1111/all.12360] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2013] [Indexed: 12/26/2022]
Abstract
BACKGROUND Sedation might improve tolerability and adherence to endoscopic procedures in patients with eosinophilic esophagitis (EoE). Propofol administration is often contraindicated in patients with hypersensitivity to egg, soy, or peanut. OBJECTIVE To investigate the safety of propofol administration for procedural sedation in EoE patients sensitized/allergic to egg, soy, peanut. METHODS A retrospective observational study in adult EoE patients undergoing esophagogastroduodenoscopy with propofol sedation was conducted between January 2009 and March 2013. Food-specific serum IgE and skin prick tests for egg, soy, peanut, and cross-reactant foods were performed in all patients. RESULTS Sixty EoE adult patients, mostly on food elimination diets (91%), were evaluated (age: 28 years (14-56), male gender (90%)). Atopy was present in 88% of patients, being the most prevalent comorbidities rhinoconjunctivitis (78%) and asthma (67%). Fifty-two patients (86%) were sensitized to either egg, soy, or peanut. Eighteen patients (28%) had a history of allergic reactions to egg, legumes, and nuts and strictly avoided these foods. A total of 404 upper endoscopies were performed under propofol sedation. No allergic adverse events were reported, except a transient bronchospasm after orotracheal intubation in an asthmatic adolescent receiving multiple drugs for anesthesia, in whom no sensitization to either propofol or its lipid vehicle was confirmed. CONCLUSIONS Propofol was safely administered for procedural sedation in a large series of adult EoE patients multisensitized to egg, soy, peanut, showing one-third clinical allergy to these foods.
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Affiliation(s)
- J Molina-Infante
- Department of Gastroenterology, Hospital San Pedro de Alcantara, Caceres, Spain
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Oh YJ, Lee HJ. Multiple cross-reactivity to several types of neuromuscular blocking agents in a patient with rocuronium anaphylaxis. Korean J Anesthesiol 2013; 65:473-4. [PMID: 24363854 PMCID: PMC3866347 DOI: 10.4097/kjae.2013.65.5.473] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Affiliation(s)
- Young-Jae Oh
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Busan, Korea
| | - Hyeon-Jeong Lee
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Busan, Korea
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Kutlu A, Karabacak E, Aydin E, Ozturk S, Bozkurt B. A patient with steroids and antihistaminic drug allergy and newly occurred chronic urticaria angioedema: what about omalizumab? Hum Exp Toxicol 2013; 33:882-5. [PMID: 24203455 DOI: 10.1177/0960327113510539] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In this case report, successful use of omalizumab in the treatment of chronic urticarial and angioedema in a 24-year-old female patient with an allergic reaction history to almost every drug including steroids and antihistamines was presented. She also had allergy against a large number of foods, which were confirmed by oral provocation, specific Immunoglobulin E and allergy skin test.
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Affiliation(s)
- A Kutlu
- Department of Allergy and Immunology, GATA Haydarpasa Training Hospital, Ankara, Turkey
| | - E Karabacak
- Department of Dermatovenereology, GATA Haydarpasa Training Hospital, Istanbul, Turkey
| | - E Aydin
- Department of Dermatovenereology, Kasimpasa Military Hospital, Istanbul, Turkey
| | - S Ozturk
- Department of Allergy and Immunology, GATA Haydarpasa Training Hospital, Ankara, Turkey
| | - B Bozkurt
- Department of Allergy and Immunology, Fatih University, Ankara, Turkey
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Stollings JL, Diedrich DA, Oyen LJ, Brown DR. Rapid-sequence intubation: a review of the process and considerations when choosing medications. Ann Pharmacother 2013; 48:62-76. [PMID: 24259635 DOI: 10.1177/1060028013510488] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE To summarize published data regarding the steps of rapid-sequence intubation (RSI); review premedications, induction agents, neuromuscular blockers (NMB), and studies supporting use or avoidance; and discuss the benefits and deficits of combinations of induction agents and NMBs used when drug shortages occur. DATA SOURCE A search of Medline databases (1966-October 2013) was conducted. STUDY SELECTION AND DATA EXTRACTION Databases were searched using the terms rapid-sequence intubation, fentanyl, midazolam, atropine, lidocaine, phenylephrine, ketamine, propofol, etomidate thiopental, succinylcholine, vecuronium, atracurium, and rocuronium. Citations from publications were reviewed for additional references. DATA SYNTHESIS Data were reviewed to support the use or avoidance of premedications, induction agents, and paralytics and combinations to consider when drug shortages occur. CONCLUSIONS RSI is used to secure a definitive airway in often uncooperative, nonfasted, unstable, and/or critically ill patients. Choosing the appropriate premedication, induction drug, and paralytic will maximize the success of tracheal intubation and minimize complications.
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The onset of enhanced intestinal permeability and food sensitivity triggered by medication used in dental procedures: a case report. Case Rep Gastrointest Med 2012; 2012:265052. [PMID: 23008786 PMCID: PMC3447324 DOI: 10.1155/2012/265052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Accepted: 08/15/2012] [Indexed: 12/12/2022] Open
Abstract
Enhanced intestinal permeability and food sensitivity are two of the many proven causes of gastrointestinal disorders. This present report describes a woman with no previous gastrointestinal (GI) complaints, who underwent dental root canal, bone graft, and implant procedures. Postsurgery she experienced an allergic reaction to the combined medications. In the weeks that followed, she presented with multiple food intolerances. Four weeks after the final dental procedure, she was assessed serologically for mucosal immune function, salivary, and blood-gluten reactivity, intestinal permeability, and other food sensitivities. Compared to her test reports from two months prior to her first dental procedure, the patient's results showed high total secretory IgA (SIgA) and elevated salivary antibodies to alpha-gliadin, indicating abnormal mucosal immunity and loss of tolerance to gluten. Her serologic assessments revealed immunoglobulin G (IgG) and IgA antibodies to a range of wheat/gluten proteins and peptides, gut bacterial endotoxins and tight junction proteins. These test results indicate gut dysbiosis, enhanced intestinal permeability, systemic gluten-reactivity, and immune response to other dietary macromolecules. The present case suggests that patients who experience severe allergic or pseudoallergic reactions to medication should be assessed and monitored for gut dysfunction. If left untreated this could lead to autoimmune reactions to self tissues.
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Florvaag E, Johansson SGO. The Pholcodine Case. Cough Medicines, IgE-Sensitization, and Anaphylaxis: A Devious Connection. World Allergy Organ J 2012; 5:73-8. [PMID: 23283141 PMCID: PMC3651177 DOI: 10.1097/wox.0b013e318261eccc] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
: The Scandinavian data on pholcodine (PHO) strongly indicates that there is a biological chain from PHO exposure through IgE-sensitization to IgE-mediated anaphylaxis to neuromuscular blocking agents (NMBA). PHO is probably one of the strongest inducer of an IgE antibody response known. Of individuals taking PHO in cough medicines, over-the-counter accessibility to large populations, as many as 20 to 25% may become IgE sensitized. Once sensitized, PHO re-exposure will booster IgE antibody levels and IgE by around 100-fold. PHO is monovalent for 2 non-cross-reacting epitopes the quaternary ammonium ion (QAI), the main allergenic epitope of NMBA, and a non-QAI epitope. Thus, PHO most unlikely would initiate an allergic inflammatory response. Consequently, IgE sensitization is not revealed by obvious clinical signs, neither through tests based on IgE-sensitized effector cells. Therefore, it will escape detection if not assayed serologically. However, when subjected to general anesthesia, and thus the IgE-sensitized individual is administered a bivalent NMBA intravenously, the unrecognized presence of serum IgE antibodies to QAI may increase the risk of anaphylaxis 200- to 300-fold. Severe damages to patient's health can result, and mortality rates of 3 to 10% are reported. The Scandinavian experience indicates that the chain of events can efficiently be avoided by stopping PHO exposure: Within 1 year, the prevalence of IgE sensitization to PHO and QAI decreases significantly, and after 2 to 3 years, the numbers of reported anaphylactic reactions decreases equally so.
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Affiliation(s)
- E Florvaag
- Laboratory of Clinical Biochemistry and Section for Clinical Allergology, Department of Occupational Medicine, Haukeland University Hospital, Bergen, Norway
- Institute of Medicine, University of Bergen, Norway
| | - SGO Johansson
- Clinical Immunology and Allergy Unit, Department of Medicine, Karolinska Institute, Stockholm, Sweden
- Department of Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden
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Cho AR, Lee HJ, Park HK, Oh YJ. Delayed Anaphylactic Shock to Intravenous Cefotetan in a Pregnant Woman. Korean J Crit Care Med 2012. [DOI: 10.4266/kjccm.2012.27.2.126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Ah-Reum Cho
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Busan, Korea
- Medical Research Institute, Pusan National University, Busan, Korea
| | - Hyeon-Jeong Lee
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Busan, Korea
- Medical Research Institute, Pusan National University, Busan, Korea
| | - Hye-Kyung Park
- Department of Internal Medicine, School of Medicine, Pusan National University, Busan, Korea
- Medical Research Institute, Pusan National University, Busan, Korea
| | - Young-Jae Oh
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Busan, Korea
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You BC, Jang AS, Han JS, Cheon HW, Park JS, Lee JH, Park SW, Kim DJ, Park CS. A case of propofol-induced oropharyngeal angioedema and bronchospasm. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2011; 4:46-8. [PMID: 22211170 PMCID: PMC3242060 DOI: 10.4168/aair.2012.4.1.46] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2011] [Accepted: 10/14/2011] [Indexed: 11/20/2022]
Abstract
Propofol (2,6-diisopropylphenol) is an ultrashort-acting sedative agent with sedative and amnestic effects that is used not only for anesthesia but also for sedation during minor outpatient procedures and endoscopic examinations. Rare cases of anaphylaxis following propofol administration have been reported in the medical literature. Documentation of anaphylaxis is often lacking because the cause and effect relationship is often hard to prove. Only a minority of patients get referred for allergy testing to confirm the offending drug. Here we report a 74-year-old woman who had an anaphylactic reaction with severe oropharyngeal edema and bronchospasm for a few minutes after receiving propofol during endoscopic examination. An allergy skin test was positive for both propofol and soybean. Soybean in the intralipid is one component of propofol, and we concluded that this anaphylaxis was caused by soybean.
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Affiliation(s)
- Byung-Chul You
- Division of Allergy and Respiratory Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
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