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Gonzalez-Estrada A, Carrillo-Martin I, Morgenstern-Kaplan D, Rukasin CRF, Rank MA, Park MA, Yee CI, Volcheck GW. A US-Based Multicenter Retrospective Report of Perioperative Anaphylaxis, 2010-2021. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024:S2213-2198(24)00342-8. [PMID: 38580206 DOI: 10.1016/j.jaip.2024.02.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 01/18/2024] [Accepted: 02/17/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND US-based perioperative anaphylaxis (POA) studies are limited to single-center experiences. A recent report found that a serum acute tryptase (sAT) >9.8 ng/mL or mast cell activation (MCA) can predict POA causal agent identification. Urinary mast cell mediator metabolites (uMC) have not been studied in POA. OBJECTIVE To analyze the epidemiologic data of POA, to determine if sAT or MCA can predict suspected causal agent identification, and to evaluate uMC utility in POA. METHODS This study is a retrospective multicenter review of POA cases that were subcategorized by suspected causal agent identification status. sAT, MCA (defined as sAT >2 + 1.2 × serum baseline tryptase), and uMC (N-methylhistamine [N-MH], 11β-prostaglandin-F2α [11β-PGF2α], leukotriene E4 [LTE4]) were recorded. RESULTS Of 100 patients (mean age 52 [standard deviation 17] years, 94% adult, 50% female, 90% White, and 2% Hispanic) with POA, 73% had an sAT available, 41% had MCA, 16% had uMC available, and 50% had an identifiable suspected cause. POA cases with an identifiable suspected cause had a positive MCA status (100% vs 78%; P = .01) compared with POA with an unidentifiable cause. An elevated median sAT did not predict causal agent identification. Positive uMC were not associated with suspected causal agent identification during POA. Patients with positive uMC had a higher median sAT (30 vs 6.45 ng/mL; P = .001) and MCA status (96% vs 12%; P = .001) compared with negative uMC patients. Patients with POA had an elevated acute/baseline uMC ratios: 11β-PGF2α ratio > 1.6, N-MH ratio >1.7, and LTE4 ratio >1.8. CONCLUSIONS The presence of MCA in POA is associated with suspected causal agent identification. Positive uMC possibly correlate with a higher sAT level and MCA status but require further study. The authors suggest applying an acute/baseline uMC ratio (11β-PGF2α ratio >1.6, N-MH ratio >1.7, and LTE4 ratio >1.87) in patients with POA for MCA when a tryptase level is inconclusive during POA evaluations.
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Affiliation(s)
- Alexei Gonzalez-Estrada
- Division of Pulmonary, Allergy and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Fla.
| | - Ismael Carrillo-Martin
- Division of Pulmonary, Allergy and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Fla
| | - Dan Morgenstern-Kaplan
- Division of Pulmonary, Allergy and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Fla
| | - Christine R F Rukasin
- Division of Allergy, Asthma and Clinical Immunology, Department of Medicine, Mayo Clinic, Scottsdale, Ariz; Division of Pulmonary, Section of Allergy/Immunology, Phoenix Children's Hospital, Phoenix, Ariz
| | - Matthew A Rank
- Division of Allergy, Asthma and Clinical Immunology, Department of Medicine, Mayo Clinic, Scottsdale, Ariz; Division of Pulmonary, Section of Allergy/Immunology, Phoenix Children's Hospital, Phoenix, Ariz
| | - Miguel A Park
- Division of Allergic Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minn
| | - Claire I Yee
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Scottsdale, Ariz
| | - Gerald W Volcheck
- Division of Allergic Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minn
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Vlaeminck N, Poorten MLVD, Nygaard Madsen C, Bech Melchiors B, Michel M, Gonzalez C, Schrijvers R, Elst J, Mertens C, Saldien V, Vitte J, Garvey LH, Sabato V, Ebo DG. Paediatric perioperative hypersensitivity: the performance of the current consensus formula and the effect of uneventful anaesthesia on serum tryptase. BJA OPEN 2024; 9:100254. [PMID: 38261931 PMCID: PMC10797541 DOI: 10.1016/j.bjao.2023.100254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 12/16/2023] [Indexed: 01/25/2024]
Abstract
Background Paired sampling of acute (aST) and basal (bST) serum tryptase has been recommended when investigating patients with a suspected perioperative hypersensitivity (POH) reaction. In the current consensus formula, an aST value exceeding (1.2×bST+2) confirms mast cell activation. The current consensus formula has been validated in adults but not in children. Methods We prospectively included 96 children who underwent uneventful anaesthesia and sampled serum tryptase at baseline and 60-90 min after induction. Tryptase changes were then compared with those in 94 children with suspected POH who were retrospectively included from four reference centres in Belgium, France, and Denmark. Results We observed a median decrease in serum tryptase during uneventful anaesthesia of 0.41 μg L-1 (-15.9%; P<0.001). The current consensus formula identified mast cell activation in 31.9% of paediatric POH patients. After generating receiver operating characteristic curves through 100 repeated five-fold cross-validation, aST>bST+0.71 was identified as the optimal cut-off point to identify mast cell activation. This new paediatric formula has higher sensitivity than the current consensus formula (53.2% vs 31.9%, P<0.001) with a specificity of 96.9%. Analysis in the subpopulation where a culprit was identified and in grade 3-4 reactions similarly yielded higher sensitivity for the new paediatric formula when compared with the current consensus formula (85.3% vs 61.8%; P=0.008 and 78.0% vs 48.8%; P<0.001, respectively). Internally cross-validated sensitivity and specificity were 53.3% and 93.3%, respectively. Conclusions This is the first study suggesting the need for an adjusted formula in children to identify perioperative mast cell activation as tryptase is significantly lowered during uneventful anaesthesia. We propose a new formula (aST>bST+0.71) which performs significantly better than the current consensus formula in our multicentric paediatric population.
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Affiliation(s)
- Nils Vlaeminck
- Department of Anaesthesiology, Antwerp University Hospital, Belgium
| | - Marie-Line van der Poorten
- Department of Immunology - Allergology - Rheumatology, Antwerp University Hospital, Belgium
- Department of Paediatrics, Faculty of Medicine and Health Science, University of Antwerp, Antwerp University Hospital, Belgium
| | - Cecilie Nygaard Madsen
- Danish Anaesthesia Allergy Centre, Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
| | - Birgitte Bech Melchiors
- Danish Anaesthesia Allergy Centre, Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
| | - Moïse Michel
- Aix-Marseille Université, MEPHI, Marseille, France
- IHU Méditerranée Infection, Marseille, France
- CHU Nîmes, Laboratoire d’Immunologie, Nîmes, France
| | - Constance Gonzalez
- Aix-Marseille Univ, University Hospitals of Marseille, Laboratoire d’Immunologie, Marseille, France
| | - Rik Schrijvers
- Department of Microbiology, Immunology and Transplantation, Faculty of Medicine, Allergy and Clinical Immunology Research Group, KU Leuven, Leuven, Belgium
| | - Jessy Elst
- Department of Immunology - Allergology - Rheumatology, Antwerp University Hospital, Belgium
| | - Christel Mertens
- Department of Immunology - Allergology - Rheumatology, Antwerp University Hospital, Belgium
| | - Vera Saldien
- Department of Anaesthesiology, Antwerp University Hospital, Belgium
| | - Joana Vitte
- University of Reims Champagne-Ardenne, INSERM UMR-S 1205 P3CELL and Immunology Laboratory, University Hospital of Reims, Reims, France
| | - Lene H. Garvey
- Danish Anaesthesia Allergy Centre, Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Denmark
| | - Vito Sabato
- Department of Immunology - Allergology - Rheumatology, Antwerp University Hospital, Belgium
| | - Didier G. Ebo
- Department of Immunology - Allergology - Rheumatology, Antwerp University Hospital, Belgium
- Department of Immunology and Allergology, AZ Jan Palfijn Ghent, Ghent, Belgium
- Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium
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Au EYL, Mak HWF, Yeung MHY, Chiang V, Lam K, Wong JCY, Yeung HHF, Chan EYT, Lau CS, Li PH. Ten-year outcomes of Perioperative Anaphylaxis Workup Study in Hong Kong (PAWS-HK): Performance of diagnostic modalities. Ann Allergy Asthma Immunol 2023:S1081-1206(23)00125-4. [PMID: 36842494 DOI: 10.1016/j.anai.2023.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 02/16/2023] [Accepted: 02/17/2023] [Indexed: 02/26/2023]
Abstract
BACKGROUND Studies on perioperative anaphylaxis (PA) in Asia are lacking. Furthermore, allergy workup for PA has largely been limited to the "silver standard" of skin tests (ST). Using in vitro tests as an adjunct to ST may improve and overcome these diagnostic challenges. OBJECTIVE To evaluate the clinical characteristics and diagnostic tests of patients with suspected PA through the Perioperative Anaphylaxis Workup Study in Hong Kong cohort. METHODS Patients with a diagnosis of PA over a 10-year period were recruited into the Perioperative Anaphylaxis Workup Study in Hong Kong. We reviewed the medical records, tryptase elevation, and diagnostic tests including ST, specific immunoglobulin E, and basophil activation tests (BAT). RESULTS In 151 patients with PA, diagnosis was reached in three-fourths of the cases (113/151, 74.8%). The most common culprits identified were neuromuscular blocking agents (25.8%), β lactams (17.2%) and chlorhexidine (13.9%). Severe anaphylaxis was associated with female sex, older age, elevated acute tryptase levels, and more cardiovascular manifestations during induction. Skin tests remained the most sensitive diagnostic modality overall (66.2%). BAT showed better performance for chlorhexidine and gelofusine anaphylaxis, with sensitivity of 80.0% and 79.6%, respectively. Specific Immunoglobulin E indicated even higher sensitivity (95.2%) than did ST (85.0%) and BAT (80.0%) for chlorhexidine anaphylaxis but performed poorly for other drugs. CONCLUSION Neuromuscular blocking agents remain the most common culprit in PA. There was a higher prevalence of gelofusine anaphylaxis in our cohort than was seen in the literature. Skin tests remain the most sensitive testing modality. In vitro tests for chlorhexidine and gelofusine showed promising results, but more studies to further elucidate its use are warranted.
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Affiliation(s)
- Elaine Y L Au
- Division of Clinical Immunology, Department of Pathology Queen Mary Hospital, Hong Kong
| | - Hugo W F Mak
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Maegan H Y Yeung
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Valerie Chiang
- Division of Clinical Immunology, Department of Pathology Queen Mary Hospital, Hong Kong
| | - Ki Lam
- Division of Clinical Immunology, Department of Pathology Queen Mary Hospital, Hong Kong
| | - Jane C Y Wong
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Heather H F Yeung
- Division of Clinical Immunology, Department of Pathology Queen Mary Hospital, Hong Kong
| | - Eric Y T Chan
- Division of Clinical Immunology, Department of Pathology Queen Mary Hospital, Hong Kong
| | - Chak-Sing Lau
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Philip H Li
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong.
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Volcheck GW, Melchiors BB, Farooque S, Gonzalez-Estrada A, Mertes PM, Savic L, Tacquard C, Garvey LH. Perioperative Hypersensitivity Evaluation and Management: A Practical Approach. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:382-392. [PMID: 36436761 DOI: 10.1016/j.jaip.2022.11.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 10/04/2022] [Accepted: 11/01/2022] [Indexed: 11/27/2022]
Abstract
Perioperative hypersensitivity (POH) is an uncommon, potentially life-threatening event. Identification of POH can be difficult given the lack of familiarity, physiological effects of anesthesia, draping of the patient during surgery, and potential nonimmunological factors contributing to signs and symptoms. Given the unique nature and large number of medications administered in the perioperative setting, evaluation of POH can be challenging. In this paper, we present a practical approach to management with an emphasis on understanding what happens in the operating room, the overlap of signs and symptoms between nonimmunological and immunological reactions, acute management, and subsequent evaluation. In addition, we provide a strategy for further review of an initially negative evaluation and emphasize the importance of establishing management plans for the patient as well as providing recommendations to the medical, anesthesia, and surgical teams for future surgeries. A critical factor for successful management at all points in the process is a close collaboration between the anesthesia and the allergy teams.
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Affiliation(s)
- Gerald W Volcheck
- Division of Allergic Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minn.
| | | | - Sophie Farooque
- Frankland Allergy Clinic, Imperial College Healthcare NHS Trust, St. Mary's Hospital, London, UK
| | - Alexei Gonzalez-Estrada
- Division of Allergy, Asthma and Clinical Immunology, Department of Medicine, Mayo Clinic, Scottsdale, AZ
| | - Paul Michel Mertes
- Department of Anesthesia and Intensive Care, Strasbourg University Hospital, Strasbourg, France
| | - Louise Savic
- Department of Anaesthesia, Leeds Teaching Hospitals, NHS Trust, Leeds, UK
| | - Charles Tacquard
- Department of Anesthesia and Intensive Care, Strasbourg University Hospital, Strasbourg, France
| | - Lene Heise Garvey
- Allergy Clinic, Department of Dermatology and Allergy, Gentofte Hospital, Gentofte, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Baldo BA. Allergic and other adverse reactions to drugs used in anesthesia and surgery. ANESTHESIOLOGY AND PERIOPERATIVE SCIENCE 2023; 1:16. [PMCID: PMC10264870 DOI: 10.1007/s44254-023-00018-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 03/02/2023] [Accepted: 04/11/2023] [Indexed: 11/13/2023]
Abstract
The list of drugs patients may be exposed to during the perioperative and postoperative periods is potentially extensive. It includes induction agents, neuromuscular blocking drugs (NMBDs), opioids, antibiotics, sugammadex, colloids, local anesthetics, polypeptides, antifibrinolytic agents, heparin and related anticoagulants, blue dyes, chlorhexidine, and a range of other agents depending on several factors related to individual patients’ clinical condition and progress in the postoperative recovery period. To avoid poor or ultrarapid metabolizers to a particular drug (for example tramadol and codeine) or possible adverse drug reactions (ADRs), some drugs may need to be avoided during or after surgery. This will be the case for patients with a history of anaphylaxis or other adverse events/intolerances to a known drug. Other drugs may be ceased for a period before surgery, e.g., anticoagulants that increase the chance of bleeding; diuretics for patients with acute renal failure; antihypertensives relative to kidney injury after major vascular surgery; and serotonergic drugs that together with some opioids may rarely induce serotonin toxicity. Studies of germline variations shown by genotyping and phenotyping to identify a predisposition of genetic factors to ADRs offer an increasingly important approach to individualize drug therapy. Studies of associations of human leukocyte antigen (HLA) genes with some serious delayed immune-mediated reactions are ongoing and variations of drug-metabolizing cytochrome CYP450 enzymes, P-glycoprotein, and catechol-O -methyltransferase show promise for the assessment of ADRs and non-responses to drugs, particularly opioids and other analgesics. Surveys of ADRs from an increasing number of institutions often cover small numbers of patients, are retrospective in nature, fail to clearly identify culprit drugs, and do not adequately distinguish immune-mediated from non-immune-mediated anaphylactoid reactions. From the many surveys undertaken, the large list of agents identified during and after anesthesia and surgery are examined for their ADR involvement. Drugs are classified into those most often involved, (NMBD and antibiotics); drugs that are becoming more frequently implicated, namely antibiotics (particularly teicoplanin), and blue dyes; those becoming less frequently involved; and drugs more rarely involved in perioperative, and postoperative adverse reactions but still important and necessary to keep in mind for the occasional potential sensitive patient. Clinicians should be aware of the similarities between drug-induced true allergic type I IgE/FcεRI- and pseudoallergic MRGPRX2-mediated ADRs, the clinical features of each, and their distinguishing characteristics. Procedures for identifying MRGPRX2 agonists and diagnosing and distinguishing pseudoallergic from allergic reaction mechanisms are discussed.
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Affiliation(s)
- Brian A. Baldo
- Molecular Immunology Unit, Kolling Institute of Medical Research, Royal North Shore Hospital of Sydney, St Leonards, Australia
- Department of Medicine, University of Sydney, Sydney, NSW Australia
- Lindfield, Australia
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Zhang K, Zeng M, Li YJ, Wu HF, Wu JC, Zhang ZS, Zheng JF, Lv YF. Antibody and complement levels in patients with hypersplenism associated with cirrhotic portal hypertension and therapeutic principles. World J Clin Cases 2022; 10:13208-13215. [PMID: 36683645 PMCID: PMC9850989 DOI: 10.12998/wjcc.v10.i36.13208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 10/30/2022] [Accepted: 11/30/2022] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Hypersplenism associated with cirrhotic portal hypertension is a common condition often resulting from hepatitis B-related cirrhosis. However, the levels of immunoglobulin (Ig) and complement in patients with hypersplenism associated with cirrhotic portal hypertension remain unclear. This study was undertaken to determine the levels of Ig and complement in these patients, the relationship between these levels and Child-Pugh class and their clinical significance.
AIM To investigate the antibody (Ig) and complement levels in patients with hypersplenism associated with cirrhotic portal hypertension and their clinical significance.
METHODS Clinical data of 119 patients with hypersplenism associated with cirrhotic portal hypertension were statistically analyzed and compared with those of 128 control patients.
RESULTS IgA and IgG levels in patients with hypersplenism were significantly higher than controls (P < 0.001). There was no significant difference in IgM between the two groups (P = 0.109). C3 and C4 levels in patients with hypersplenism were significantly lower than controls (P < 0.001). As liver function decreased, IgA and IgG levels increased (P < 0.001), and C3 and C4 levels decreased (P < 0.001).
CONCLUSION Patients with hypersplenism associated with cirrhotic portal hypertension have significantly higher antibody (IgA and IgG) levels and significantly lower complement (C3 and C4) levels, which are both related to liver damage. Clinically, the administration of anti-hepatitis virus agents and protection of liver function should be strengthened.
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Affiliation(s)
- Kun Zhang
- Department of Geriatric Center, Hainan General Hospital, Haikou 570311, Hainan Province, China
| | - Min Zeng
- Department of Geriatric Center, Hainan General Hospital, Haikou 570311, Hainan Province, China
| | - Ye-Juan Li
- Reproductive Medicine Center, Maternal and Child Health Care Hospital of Hainan Province, Haikou 570311, Hainan Province, China
| | - Hong-Fei Wu
- Department of General Surgery, Hainan General Hospital, Haikou 570311, Hainan Province, China
| | - Jin-Cai Wu
- Department of General Surgery, Hainan General Hospital, Haikou 570311, Hainan Province, China
| | - Zhen-Sheng Zhang
- Department of General Surgery, Hainan General Hospital, Haikou 570311, Hainan Province, China
| | - Jin-Fang Zheng
- Department of General Surgery, Hainan General Hospital, Haikou 570311, Hainan Province, China
| | - Yun-Fu Lv
- Department of General Surgery, Hainan General Hospital, Haikou 570311, Hainan Province, China
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Could Artificial Intelligence Prevent Intraoperative Anaphylaxis? Reference Review and Proof of Concept. Medicina (B Aires) 2022; 58:medicina58111530. [PMID: 36363487 PMCID: PMC9694532 DOI: 10.3390/medicina58111530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 10/17/2022] [Accepted: 10/24/2022] [Indexed: 01/25/2023] Open
Abstract
Drugs and various medical substances have been used for many decades to diagnose or treat diseases. Procedures like surgery and anesthesia (either local or general) use different pharmacological products during these events. In most of the cases, the procedure is safe and the physician performs the technique without incidents. Although they are safe for use, these substances (including drugs) may have adverse effects, varying from mild ones to life-threatening reactions in a minority of patients. Artificial intelligence may be a useful tool in approximating the risk of anaphylaxis before undertaking a medical procedure. This material presents these undesirable responses produced by medical products from a multidisciplinary point of view. Moreover, we present a proof of concept for using artificial intelligence as a possible guardship against intraoperative anaphylaxis.
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Incidence of intraoperative anaphylaxis caused by blood products: a 12-year single-center, retrospective study. J Anesth 2022; 36:390-398. [PMID: 35416534 DOI: 10.1007/s00540-022-03059-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 03/23/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Intraoperative anaphylaxis caused by blood products is uncommon, but it is unclear whether the rarity of this reaction is attributable to the difficulty of diagnosis, underreporting, or both. We investigated the incidence of intraoperative transfusion anaphylaxis and its reporting to the hemovigilance system. METHODS We retrospectively reviewed cases wherein general anesthesia was used at a single hospital during a 12-year period. Cases of intraoperative anaphylaxis were extracted using an electronic search strategy and determined using the recently developed grading and clinical scoring system. The causative blood products were determined by the onset duration based on literature regarding intraoperative transfusion anaphylaxis cases. RESULTS Among the 62,146 general anesthesia cases, 22 cases of intraoperative anaphylaxis were identified, and 11 of the 22 cases received transfusions before the onset of anaphylaxis. Intraoperative transfusion anaphylaxis was defined as occurring within 30 min of transfusion. Finally, nine cases of intraoperative transfusion anaphylaxis were analyzed. The overall incidence of intraoperative transfusion anaphylaxis was 1/3,994, with the highest incidence noted for fresh frozen plasma (1/2146; 95% confidence interval [CI] 1/6610-1/920), platelet concentrate (1/2348; 95% CI 1/92,742-1/422), and red blood cells (1/22,867; 95% CI 1/903,199-1/4,105). No evidence indicated that these cases were reported to the Japanese hemovigilance system, although all intraoperative transfusion anaphylaxis cases were diagnosed by anesthesiologists. CONCLUSION The incidence of intraoperative anaphylaxis caused by blood products was higher than that reported and may be underreported to the Japanese hemovigilance system. Further research, particularly multicenter studies, is needed to confirm our results.
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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 (PA) is a rare but life-threatening condition that poses diagnostic and management challenges in the operating room. The incidence of severe perioperative reactions is estimated to be approximately 1:7000-10,000. Management involves both immediate stabilization of the patient and identifying the culprit agent. Identification is essential to prevent recurrence of the event in subsequent surgeries and to avoid unnecessary labeling of drug allergy. Identifying all possible exposures including medications, disinfectants, latex, and dyes and choosing the appropriate tests are essential for proper evaluation. To identify the culprit, primary testing modalities include tryptase at the time of the reaction with subsequent levels and skin testing with nonirritating concentrations to the medications and substances utilized during the procedure and those potentially used as alternates. This strategy provides guidance for future surgeries and procedures. Close collaboration between the allergy, anesthesiology, and surgery teams is essential for appropriate management of these patients at the time of the reaction, during the post event evaluation and in preparation for subsequent surgeries.
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Banerji A, Bhattacharya G, Huebner E, Fu X, Camargo CA, Guyer A, Kuhlen JL, Blumenthal KG. Perioperative Allergic Reactions: Allergy Assessment and Subsequent Anesthesia. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:1980-1991. [PMID: 33248280 DOI: 10.1016/j.jaip.2020.11.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 10/26/2020] [Accepted: 11/09/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Evidence-based guidelines are needed in the United States to improve evaluation of perioperative allergic reactions including recommendations for subsequent anesthesia. OBJECTIVE To identify causative agent(s) and evaluate patients' tolerability of subsequent anesthesia in patients evaluated by Allergy/Immunology (A/I) at Massachusetts General Hospital. METHODS We performed a retrospective review of patients referred to the outpatient A/I clinic for perioperative allergic reactions between October 2003 and May 2017. Patient demographics, atopic history, and prior adverse drug reactions were reviewed. Patients underwent a comprehensive evaluation with testing including skin testing (ST), drug challenges (when appropriate), tryptase level measurement, and specific IgE to latex measurement. Tolerance of subsequent procedures requiring anesthesia was assessed. RESULTS Of 123 patients referred, 74 (60%) were female and the mean age was 46 (±18) years. At least 1 causative agent was identified in 28 patients (24%, n = 28 of 118). Seventeen of 28 (61%) patients were ST positive to an antibiotic, including 13 (46%) positive to cefazolin; 3 patients (11%) had a positive latex specific IgE. Of 85 patients who had subsequent anesthesia with a known outcome, 78 (91%) did not have another perioperative allergic reaction. Two of 5 patients with an elevated baseline tryptase level did not tolerate subsequent anesthesia. CONCLUSION The majority of patients safely received subsequent anesthesia after comprehensive A/I evaluation for their perioperative allergic reactions; however, improved algorithmic care is needed in the United States. Among ST-positive patients (24%), antibiotics (especially cefazolin) were the most common culprits. An elevated baseline tryptase level was associated with an increased risk of recurrent perioperative allergic reactions.
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Affiliation(s)
- Aleena Banerji
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass.
| | - Gita Bhattacharya
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | - Emily Huebner
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | - Xiaoqing Fu
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | - Carlos A Camargo
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass; Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Mass
| | - Autumn Guyer
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California San Francisco, San Francisco, Calif
| | - James L Kuhlen
- Department of Medicine, Apex Allergy and Immunology, Greenville, SC
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass; Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital, Boston, Mass
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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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14
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Gonzalez-Estrada A, Carrillo-Martin I, Renew JR, Rank MA, Campbell RL, Volcheck GW. Incidence of and risk factors for perioperative or periprocedural anaphylaxis in the United States from 2005 to 2014. Ann Allergy Asthma Immunol 2020; 126:180-186.e3. [PMID: 33068738 DOI: 10.1016/j.anai.2020.10.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 09/16/2020] [Accepted: 10/07/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND The estimated worldwide incidence of perioperative or periprocedural anaphylaxis (PA) is between 1 in 1250 and 1 in 20,000 procedures. OBJECTIVE To evaluate the incidence of PA in the United States and compare patient characteristics and underlying risk factors using a large national database. METHODS Using deidentified data from the nationwide inpatient sample from 2005 to 2014, we identified cases of PA through the International Classification of Diseases, Ninth Revision, Clinical Modification codes and conducted a retrospective analysis. RESULTS Among 35,647,347 surgeries and procedures, there were 5458 (0.015%) PA cases identified. The incidence of PA was 15.3 cases per 100,000 procedures. When compared with controls, PA cases had an increased mortality (3.4% vs 1.4%; P < .001), median length of stay (5 vs 3 days; P < .001), and median hospital cost ($45,155 vs $24,734; P < .001). The age group between 18 and 34 years (odds ratio [OR], 1.34; 95% confidence interval [CI], 1.13-1.58; P < .001) and female sex (OR, 1.40; 95% CI, 1.31-1.49; P < .001) were associated with increased odds of PA. Transplant (OR, 3.35; 95% CI, 2.59-4.34; P < .001), hematologic (OR, 1.63; 95% CI, 1.30-2.05; P < .001), vascular (OR, 1.49; 95% CI, 1.30-1.67; P < .001), and cardiac (OR, 1.47; 95% CI, 1.30-1.67; P < .001) procedures were at increased risk for PA. Several comorbidities were associated with PA including chronic pulmonary disease (OR, 1.41; 95% CI, 1.31-1.51; P < .001). CONCLUSION The incidence of PA is 1 in 6531 procedures, with a mortality of 1 in 191,652 procedures. PA has worsening outcomes compared with controls. The risk factors of PA include age, sex, procedure type, and comorbidities.
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Affiliation(s)
- Alexei Gonzalez-Estrada
- Division of Pulmonary, Allergy and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Florida.
| | - Ismael Carrillo-Martin
- Division of Pulmonary, Allergy and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Florida
| | - J Ross Renew
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida
| | - Matthew A Rank
- Division of Allergy, Asthma and Clinical Immunology, Department of Medicine, Mayo Clinic, Scottsdale, Arizona
| | - Ronna L Campbell
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota
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15
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Devinck A, Bauters T, Lapeere H, Willems L. Anaphylaxis related to disinfection with chlorhexidine in a teenager treated for cancer. J Oncol Pharm Pract 2020; 27:227-231. [PMID: 32476588 DOI: 10.1177/1078155220925531] [Citation(s) in RCA: 1] [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
INTRODUCTION Literature shows upcoming allergy to chlorhexidine due to the widespread use of the disinfectant within and outside surgical settings. Only a few case reports have been published regarding the use of topical chlorhexidine disinfectant outside surgery and only a minority of these within the pediatric population. CASE REPORT We present a case-report of a teenager, treated for acute lymphoblastic leukemia who developed an anaphylactic shock after repeated chlorhexidine use for skin disinfection at the insertion of a central venous catheter during his chemotherapy treatment. Preceding minor symptoms such as local swelling and pruritus were not recognized as possible allergy to chlorhexidine.Management and outcome: He was treated with two doses of intramuscular adrenaline and transferred to the pediatric intensive care unit where he fully recovered. Specific IgE testing was positive for chlorhexidine. A total avoidance of chlorhexidine was instructed. DISCUSSION A similar case was published regarding an anaphylaxis after use of chlorhexidine disinfectant for a dialysis catheter. Almost all other case reports of anaphylactic shock were found within surgical settings or after insertion of an impregnated central venous catheter/urine catheter. We suggest that some of the disinfectant might have been flushed in the catheter and then caused an anaphylactic reaction. The link between symptoms and chlorhexidine was not made until an anaphylactic reaction occurred. Literature data show that chlorhexidine often causes mild preceding symptoms before an anaphylaxis occurs. So let awareness arise around this 'hidden allergen' of which warning reactions often are being missed.
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Affiliation(s)
- Astrid Devinck
- Division of Pediatric Haemato-Oncology and Stem Cell Transplantation, Department of Pediatrics, Ghent University Hospital, Ghent, Belgium
| | - Tiene Bauters
- Division of Pediatric Haemato-Oncology and Stem Cell Transplantation, Department of Pediatrics, Ghent University Hospital, Ghent, Belgium.,Pharmacy Department, Ghent University Hospital, Ghent, Belgium
| | - Hilde Lapeere
- Department of Dermatology, Ghent University Hospital, Ghent, Belgium
| | - Leen Willems
- Division of Pediatric Haemato-Oncology and Stem Cell Transplantation, Department of Pediatrics, Ghent University Hospital, Ghent, Belgium
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van Cuilenborg VR, Hermanides J, Bos EME, Hollmann MW, Preckel B, Kooij FO, Terreehorst I. Perioperative approach of allergic patients. Best Pract Res Clin Anaesthesiol 2020; 35:11-25. [PMID: 33742571 DOI: 10.1016/j.bpa.2020.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 03/23/2020] [Indexed: 12/18/2022]
Abstract
Perioperative allergic reactions are rare, yet important complications of anesthesia. Severe, generalized allergic reactions called anaphylaxis are estimated to have a mortality of 3.5-4.8%. Adequate recognition and handling of a severe perioperative anaphylactic reaction result in better outcomes, including less hypoxic-ischemic encephalopathy and death. The diagnosis of a perioperative allergic reaction can be difficult as the list of possible culprits of a perioperative allergic reaction is extensive. Making an informed guess on the causative agent and avoiding this agent in future anesthesia procedures is undesirable and unsafe. Therefore, to ensure future patient safety, a thorough investigation following a perioperative allergic reaction is mandatory. A collaborate approach by allergists and anesthesiologists is advised. In this article, we discuss the basic approach of the allergic patient and of patients with a suspected allergy to perioperatively administered medication.
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Affiliation(s)
- Vincent R van Cuilenborg
- Dutch Perioperative Allergy Centre, Amsterdam University Medical Centres, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands; Department of Anaesthesiology, Amsterdam University Medical Centres, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.
| | - Jeroen Hermanides
- Dutch Perioperative Allergy Centre, Amsterdam University Medical Centres, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands; Department of Anaesthesiology, Amsterdam University Medical Centres, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.
| | - Elke M E Bos
- Dutch Perioperative Allergy Centre, Amsterdam University Medical Centres, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands; Department of Anaesthesiology, Amsterdam University Medical Centres, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.
| | - Markus W Hollmann
- Department of Anaesthesiology, Amsterdam University Medical Centres, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.
| | - Benedikt Preckel
- Department of Anaesthesiology, Amsterdam University Medical Centres, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.
| | - Fabian O Kooij
- Dutch Perioperative Allergy Centre, Amsterdam University Medical Centres, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands; Department of Anaesthesiology, Amsterdam University Medical Centres, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.
| | - Ingrid Terreehorst
- Dutch Perioperative Allergy Centre, Amsterdam University Medical Centres, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands; Department of Otorhinolaryngology, Amsterdam University Medical Centres, Location AMC, Meibergdreef 9, 1105 AZ, the Netherlands.
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Garvey LH, Ebo DG, Mertes P, Dewachter P, Garcez T, Kopac P, Laguna JJ, Chiriac AM, Terreehorst I, Voltolini S, Scherer K. An EAACI position paper on the investigation of perioperative immediate hypersensitivity reactions. Allergy 2019; 74:1872-1884. [PMID: 30964555 DOI: 10.1111/all.13820] [Citation(s) in RCA: 114] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Accepted: 03/19/2019] [Indexed: 12/12/2022]
Abstract
Perioperative immediate hypersensitivity reactions are rare. Subsequent allergy investigation is complicated by multiple simultaneous drug exposures, the use of drugs with potent effects and the many differential diagnoses to hypersensitivity in the perioperative setting. The approach to the investigation of these complex reactions is not standardized, and it is becoming increasingly apparent that collaboration between experts in the field of allergy/immunology/dermatology and anaesthesiology is needed to provide the best possible care for these patients. The EAACI task force behind this position paper has therefore combined the expertise of allergists, immunologists and anaesthesiologists. The aims of this position paper were to provide recommendations for the investigation of immediate-type perioperative hypersensitivity reactions and to provide practical information that can assist clinicians in planning and carrying out investigations.
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Affiliation(s)
- Lene Heise Garvey
- Danish Anaesthesia Allergy Centre, Allergy Clinic, Department of Dermatology and Allergy Copenhagen University Hospital Gentofte Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
| | - Didier G. Ebo
- Faculty of Medicine and Health Science, Department of Immunology – Allergology – Rheumatology Antwerp University Hospital, University of Antwerp Antwerp Belgium
| | - Paul‐Michel Mertes
- Department of Anesthesia and Intensive Care Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, EA 3072, FMTS de Strasbourg Strasbourg France
| | - Pascale Dewachter
- Service d’Anesthésie‐Réanimation, Groupe Hospitalier de Paris‐Seine‐Saint‐Denis Assistance Publique‐Hôpitaux de Paris & Université Paris 13, Sorbonne Paris Cité Paris France
| | - Tomaz Garcez
- Immunology Department Manchester University NHS Foundation Trust Manchester UK
| | - Peter Kopac
- University Clinic of Respiratory and Allergic Diseases Golnik Slovenia
| | - José Julio Laguna
- Allergy Unit, Allergo‐Anaesthesia Unit, Faculty of Medicine Hospital Central de la Cruz Roja, Alfonso X El Sabio University, ARADyAL Madrid Spain
| | - Anca Mirela Chiriac
- Allergy Unit, Département de Pneumologie et Addictologie, Hôpital Arnaud de Villeneuve University Hospital of Montpellier Montpellier France
- Sorbonnes Universités, UPMC Paris 06, UMR‐S 1136, IPLESP, Equipe EPAR Paris France
| | - Ingrid Terreehorst
- Department of ENT and DPAC AUMCAmsterdam University Medical Center Amsterdam The Netherlands
| | | | - Kathrin Scherer
- Allergy Unit, Department of Dermatology, University Hospital University of Basel Basel Switzerland
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Ebo DG, Van Gasse AL, Decuyper II, Uyttebroek A, Sermeus LA, Elst J, Bridts CH, Mertens CM, Faber MA, Hagendorens MM, De Clerck LS, Sabato V. Acute Management, Diagnosis, and Follow-Up of Suspected Perioperative Hypersensitivity Reactions in Flanders 2001-2018. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:2194-2204.e7. [DOI: 10.1016/j.jaip.2019.02.031] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 01/25/2019] [Accepted: 02/15/2019] [Indexed: 12/20/2022]
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Comparative epidemiology of suspected perioperative hypersensitivity reactions. Br J Anaesth 2019; 123:e16-e28. [PMID: 30916015 DOI: 10.1016/j.bja.2019.01.027] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 12/24/2018] [Accepted: 01/15/2019] [Indexed: 12/31/2022] Open
Abstract
Suspected perioperative hypersensitivity reactions are rare but contribute significantly to the morbidity and mortality of surgical procedures. Recent publications have highlighted the differences between countries concerning the respective risk of different drugs, and changes in patterns of causal agents and the emergence of new allergens. This review summarises recent information on the epidemiology of perioperative hypersensitivity reactions, with specific consideration of differences between geographic areas for the most frequently involved offending agents.
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Woldegerima YB, Kemal SD. Clinical Audit on the Practice of Documentation at Preanesthetic Evaluation in a Specialized University Hospital. Anesth Essays Res 2019; 12:819-824. [PMID: 30662114 PMCID: PMC6319065 DOI: 10.4103/aer.aer_131_18] [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] [Indexed: 11/07/2022] Open
Abstract
Background: Performing preanesthetic evaluation, documenting, and keeping readily accessible record are responsibilities of anesthetists. Documentation can improve overall patient outcome. It also has an irreplaceable role in medico-legal aspects. Documentation is one of the challenges of providing quality care. Aim: The aim of this study was to evaluate the quality of documentation practice during preanesthetic visits. Materials and Methods: This clinical audit was conducted in the University of Gondar Hospital. Predefined 22 practice quality indicators were prepared according to modified global quality index. Statistical Analysis: Descriptive statistics was performed using SPSS version 20. Results: A total of 122 preanesthetic evaluation tools (PAETs) were reviewed. None of PAETs found fully completed according to the indicators. Trends differ between elective and emergency conditions. Indicators with high completion rate (>90%) were signed a consent, medical history, history of medication, allergy, anesthesia and surgery, cardiopulmonary examination, airway examination, preoperative diagnosis, and planned procedure. Anesthetic plan, vital signs, a name, per-oral status, premedication, and age were found with below average (<50%) completion rate. Conclusions: Documentation practice during the preanesthetic visit was below the standard. Unclear instructions should be replaced with standardized contents. Providing regular trainings on clinical documentation for students and staffs, and introducing modern electronic-based documentation system and preanesthetic clinics may improve the practice.
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Affiliation(s)
- Yophtahe B Woldegerima
- Department of Anesthesia, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Semira D Kemal
- Department of Anesthesia, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Khan DA, Banerji A, Bernstein JA, Bilgicer B, Blumenthal K, Castells M, Ein D, Lang DM, Phillips E. Cephalosporin Allergy: Current Understanding and Future Challenges. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2019; 7:2105-2114. [PMID: 31495420 PMCID: PMC6955146 DOI: 10.1016/j.jaip.2019.06.001] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 05/29/2019] [Accepted: 06/02/2019] [Indexed: 01/13/2023]
Abstract
Cephalosporins are commonly used antibiotics both in hospitalized patients and in outpatients. Hypersensitivity reactions to cephalosporins are becoming increasingly common with a wide range of immunopathologic mechanisms. Cephalosporins are one of the leading causes for perioperative anaphylaxis and severe cutaneous adverse reactions. Patients allergic to cephalosporins tend to tolerate cephalosporins with disparate R1 side chains but may react to other beta-lactams with common R1 side chains. Skin testing for cephalosporins has not been well validated but appears to have a good negative predictive value for cephalosporins with disparate R1 side chains. In vitro tests including basophil activation tests have lower sensitivity when compared with skin testing. Rapid drug desensitization procedures are safe and effective and have been used successfully for immediate and some nonimmediate cephalosporin reactions. Many gaps in knowledge still exist regarding cephalosporin hypersensitivity.
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Affiliation(s)
- David A. Khan
- Department of Internal Medicine, Division of Allergy & Immunology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-8859
| | - Aleena Banerji
- Department of Medicine, Division of Rheumatology, Allergy & Immunology, Massachusetts General Hospital, Cox 201, MGH, 55 Fruit St, Boston, MA 02114
| | - Jonathan A. Bernstein
- Department of Internal Medicine, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML#563, Cincinnati, OH 45267-0563
| | - Basar Bilgicer
- Department of Chemical and Biomedical Engineering, 205 McCourtney Hall, Notre Dame, IN 46556-5637
| | - Kimberly Blumenthal
- Department of Medicine, Division of Rheumatology, Allergy & Immunology, Massachusetts General Hospital, Cox 201, MGH, 55 Fruit St, Boston, MA 02114
| | - Mariana Castells
- Department of Medicine, Division of Rheumatology, Allergy and Immunology, Brigham and Women’s Hospital, 60 Fenwood Rd Hale Building, Boston, MA 02115
| | - Daniel Ein
- Department of Internal Medicine, George Washington University Medical Center, 2300 M St. NW, Washington DC 20037
| | - David M. Lang
- Department of Internal Medicine, Cleveland Clinic, Respiratory Institute, Department of Allergy and Clinical Immunology, 9500 Euclid Ave-A90, Cleveland, OH 44195
| | - Elizabeth Phillips
- Department of Medicine, Vanderbilt University Medical Center, 1161-21 St Ave S, A-2200 MCN, Nashville, TN 3732-2582
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Woldegerima Y, Kemal S. Clinical audit on the practice of documentation at preanesthetic evaluation in a specialized university hospital. INTERNATIONAL JOURNAL OF SURGERY OPEN 2019. [DOI: 10.1016/j.ijso.2018.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Che D, Wang J, Ding Y, Liu R, Cao J, Zhang Y, Hou Y, An H, Gao Z, Zhang T. Mivacurium induce mast cell activation and pseudo-allergic reactions via MAS-related G protein coupled receptor-X2. Cell Immunol 2018; 332:121-128. [DOI: 10.1016/j.cellimm.2018.08.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 07/27/2018] [Accepted: 08/09/2018] [Indexed: 11/28/2022]
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Di Leo E, Delle Donne P, Calogiuri GF, Macchia L, Nettis E. Focus on the agents most frequently responsible for perioperative anaphylaxis. Clin Mol Allergy 2018; 16:16. [PMID: 30002605 PMCID: PMC6038250 DOI: 10.1186/s12948-018-0094-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 06/23/2018] [Indexed: 11/27/2022] Open
Abstract
Adverse reactions (ARs) to drugs administered during general anesthesia may be very severe and life-threatening, with a mortality rate ranging from 3 to 9%. The adverse reactions to drugs may be IgE and non-IgE-mediated. Neuromuscular blocking agents (NMBA) represent the first cause of perioperative reactions during general anesthesia followed by latex, antibiotics, hypnotic agents, opioids, colloids, dyes and antiseptics (chlorhexidine). All these substances (i.e. NMBA, anesthetics, antibiotics, latex devices) may cause severe systemic non-IgE-mediated reactions or fatal anaphylactic events even in the absence of any evident risk factor in the patient's anamnesis. For this reason, in order to minimize perioperative anaphylactic reactions, it is important to have rapid, specific, sensitive in vitro diagnostic tests able to confirm the clinical diagnosis of acute anaphylaxis.
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Affiliation(s)
- E. Di Leo
- Unit of Internal Medicine, Section of Allergy and Clinical Immunology, “F. Miulli” Hospital, Acquaviva delle Fonti, BA Italy
| | - P. Delle Donne
- Department of Emergency and Organ Transplantation, School and Chair of Allergology and Clinical Immunology, University of Bari—Aldo Moro, Bari, Italy
| | - G. F. Calogiuri
- Pneumology Department, Sacro Cuore Hospital, Gallipoli, Lecce, Italy
| | - L. Macchia
- Department of Emergency and Organ Transplantation, School and Chair of Allergology and Clinical Immunology, University of Bari—Aldo Moro, Bari, Italy
| | - E. Nettis
- Department of Emergency and Organ Transplantation, School and Chair of Allergology and Clinical Immunology, University of Bari—Aldo Moro, Bari, Italy
- Policlinico, Piazza Giulio Cesare, 11, 70124 Bari, Italy
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In Vitro Diagnosis of Immediate Drug Hypersensitivity During Anesthesia: A Review of the Literature. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:1176-1184. [DOI: 10.1016/j.jaip.2018.01.004] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 01/05/2018] [Accepted: 01/16/2018] [Indexed: 02/07/2023]
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Abstract
Background For most physicians, quantification of drug-specific immunoglobulin E (drug-sIgE) antibodies constitutes the primary in vitro measure to document immediate drug hypersensitivity reactions (IDHR). Unfortunately, this is often insufficient to correctly identify patients with IgE-mediated IDHR and impossible for non-IgE-mediated IDHR that result from alternative routes of basophil and mast cell activation. In these difficult cases, diagnosis might benefit from cellular tests such as basophil activation tests (BAT). Aim The aim was to review the potential and limitations of quantification of sIgE and BAT in diagnosing IDHR. The utility of quantification of serum tryptase is discussed. Methods A literature search was conducted using the key words allergy, basophil activation, CD63, CD203c, diagnosis, drugs, hypersensitivity, flow cytometry, specific IgE antibodies; this was complemented by the authors’ own experience. Results The drugs that have been most studied with both techniques are β-lactam antibiotics and curarizing neuromuscular blocking agents (NMBA). For sIgE morphine, data are available on the value of this test as a biomarker for sensitization to substituted ammonium structures that constitute the major epitope of NMBA, especially rocuronium and suxamethonium. For the BAT, there are also data on non-steroidal anti-inflammatory drugs (NSAIDs) and iodinated radiocontrast media. For β-lactam antibiotics, sensitivity and specificity of sIgE varies between 0 and 85% and 52 and 100%, respectively. For NMBA, sensitivity and specificity varies between 38.5 and 92% and 85.7 and 100%, respectively. Specific IgE to morphine should not be used in isolation to diagnose IDHR to NMBA nor opiates. For the BAT, sensitivity generally varies between 50 and 60%, whereas specificity attains 80%, except for quinolones and NSAIDs. Conclusions Although drug-sIgE assays and BAT can provide useful information in the diagnosis of IDHR, their predictive value is not absolute. Large-scale collaborative studies are mandatory to harmonize and optimize test protocols and to establish drug-specific decision thresholds.
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Lasa EM, González C, García-Lirio E, Martínez S, Arroabarren E, Gamboa PM. Anaphylaxis caused by immediate hypersensitivity to topical chlorhexidine in children. Ann Allergy Asthma Immunol 2017; 118:118-119. [PMID: 28007083 DOI: 10.1016/j.anai.2016.10.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Revised: 09/28/2016] [Accepted: 10/13/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Eva María Lasa
- Servicio de Alergología, Hospital Universitario Donostia, San Sebastián, España.
| | - Carlos González
- Servicio de Alergología, Hospital Universitario de Basurto, Bilbao, España
| | | | - Sara Martínez
- Servicio de Alergología, Hospital Universitario Donostia, San Sebastián, España
| | - Esozia Arroabarren
- Servicio de Alergología, Complejo Hospitalario de Navarra, Pamplona, España
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Iammatteo M, Keskin T, Jerschow E. Evaluation of periprocedural hypersensitivity reactions. Ann Allergy Asthma Immunol 2017; 119:349-355.e2. [DOI: 10.1016/j.anai.2017.07.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 07/08/2017] [Accepted: 07/11/2017] [Indexed: 12/18/2022]
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Bahal S, Sharma S, Garvey LH, Nagendran V. Anaphylaxis after disinfection with 2% chlorhexidine wand applicator. BMJ Case Rep 2017; 2017:bcr-2017-219794. [PMID: 28790050 DOI: 10.1136/bcr-2017-219794] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
A 54-year-old man with end-stage renal failure attended for dialysis. Within seconds of applying 2% w/v chlorhexidine (ChloraPrep 3 mL Wand Applicator) to the skin surrounding the insertion point of his dialysis catheter (Tesio catheter), he developed pruritus, urticaria, shortness of breath, hypotension and reduced responsiveness. Treatment for anaphylaxis was initiated with rapid improvement of his symptoms, and he made a full recovery. Allergy to chlorhexidine was confirmed with skin testing, and the patient was warned against all future exposure to chlorhexidine. Subsequent dialysis without chlorhexidine was uneventful.
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Affiliation(s)
- Sameer Bahal
- Department of Immunology, Barts Health NHS Trust, London, UK
| | - Samriti Sharma
- Critical Care Department, University College London Hospitals NHS Foundation Trust, London, UK
| | - Lene Heise Garvey
- Department of Dermatology and Allergy, Danish Anaesthesia Allergy Centre, Gentofte Hospital, Hellerup, Denmark
| | - Vasantha Nagendran
- Department of Immunology, Epsom and Saint Helier University Hospitals NHS Trust, Carshalton, UK
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Reclassifying Anaphylaxis to Neuromuscular Blocking Agents Based on the Presumed Patho-Mechanism: IgE-Mediated, Pharmacological Adverse Reaction or "Innate Hypersensitivity"? Int J Mol Sci 2017; 18:ijms18061223. [PMID: 28590439 PMCID: PMC5486046 DOI: 10.3390/ijms18061223] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 06/01/2017] [Accepted: 06/02/2017] [Indexed: 01/18/2023] Open
Abstract
Approximately 60% of perioperative anaphylactic reactions are thought to be immunoglobulin IgE mediated, whereas 40% are thought to be non-IgE mediated hypersensitivity reactions (both considered non-dose-related type B adverse drug reactions). In both cases, symptoms are elicited by mast cell degranulation. Also, pharmacological reactions to drugs (type A, dose-related) may sometimes mimic symptoms triggered by mast cell degranulation. In case of hypotension, bronchospasm, or urticarial rash due to mast cell degranulation, identification of the responsible mechanism is complicated. However, determination of the type of the underlying adverse drug reaction is of paramount interest for the decision of whether the culprit drug may be re-administered. Neuromuscular blocking agents (NMBA) are among the most frequent cause of perioperative anaphylaxis. Recently, it has been shown that NMBA may activate mast cells independently from IgE antibodies via the human Mas-related G-protein-coupled receptor member X2 (MRGPRX2). In light of this new insight into the patho-mechanism of pseudo-allergic adverse drug reactions, in which as drug-receptor interaction results in anaphylaxis like symptoms, we critically reviewed the literature on NMBA-induced perioperative anaphylaxis. We challenge the dogma that NMBA mainly cause IgE-mediated anaphylaxis via an IgE-mediated mechanism, which is based on studies that consider positive skin test to be specific for IgE-mediated hypersensitivity. Finally, we discuss the question whether MRGPRX2 mediated pseudo-allergic reactions should be re-classified as type A adverse reactions.
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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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Perioperative Anaphylaxis to Chlorhexidine during Surgery and Septoplasty. Case Rep Otolaryngol 2017; 2017:9605804. [PMID: 28409044 PMCID: PMC5376445 DOI: 10.1155/2017/9605804] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 02/20/2017] [Accepted: 02/27/2017] [Indexed: 11/17/2022] Open
Abstract
Chlorhexidine is an antiseptic and disinfectant used in surgical and clinical practice since 1954 and is available in aqueous or alcoholic solutions 0.5%-4.0% and has a broad-spectrum activity. Despite their widespread use, allergic reactions with chlorhexidine are rarely reported. We describe a case of anaphylaxis with chlorhexidine during a septoplasty, turbinectomy, and maxillary sinusectomy. The patient presented with periorbital edema, hives, hypotension, and wheezing. Immediately after the diagnosis of anaphylaxis promethazine, hydrocortisone, and epinephrine were administered with immediate clinical improvement. This case highlights the importance of assessing whether there is a previous clinical history of hypersensitivity to chlorhexidine in patients who will undergo surgical procedures.
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Meng J, Rotiroti G, Burdett E, Lukawska JJ. Anaphylaxis during general anaesthesia: experience from a drug allergy centre in the UK. Acta Anaesthesiol Scand 2017; 61:281-289. [PMID: 28164272 DOI: 10.1111/aas.12858] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 12/21/2016] [Accepted: 12/27/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND Anaphylaxis during general anaesthesia is rare but often severe. Identification of the cause of anaphylaxis and recommendation of a range of drugs or agents likely to be safer for future surgery is a collaborative venture between the allergists and the anaesthesiologists, but it often poses a significant challenge. METHODS A total of 31 patients who attended the Drug Allergy Unit at University College London Hospital with suspected perioperative anaphylaxis between March 2013 and January 2016 were reviewed retrospectively. RESULTS The culprit drug was identified in 21 patients (67.7%): antibiotics (n = 11, 52.3%), neuromuscular blocking agents (n = 8, 38.1%), morphine (n = 1, 4.8%) and gelofusine (n = 1, 4.8%). No cause was identified in six patients (19.4%), and four patients (12.9%) had non-allergic reactions. CONCLUSION Our results confirm that antibiotics and neuromuscular blocking agents are common causative agents of perioperative anaphylaxis in the United Kingdom.
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Affiliation(s)
- J. Meng
- Otolaryngology Department; West China Hospital; Sichuan University; Chengdu China
- Department of Specialist Allergy and Clinical Immunology; Royal National Throat Nose Ear Hospital; University College London Hospital; London UK
| | - G. Rotiroti
- Department of Specialist Allergy and Clinical Immunology; Royal National Throat Nose Ear Hospital; University College London Hospital; London UK
| | - E. Burdett
- Department of Anaesthetics; University College London Hospital; London UK
| | - J. J. Lukawska
- Department of Specialist Allergy and Clinical Immunology; Royal National Throat Nose Ear Hospital; University College London Hospital; London UK
- Department of Imaging Sciences; King's College London; London UK
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Uyttebroek AP, Decuyper II, Bridts CH, Romano A, Hagendorens MM, Ebo DG, Sabato V. Cefazolin Hypersensitivity: Toward Optimized Diagnosis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2016; 4:1232-1236. [DOI: 10.1016/j.jaip.2016.05.011] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 05/04/2016] [Accepted: 05/13/2016] [Indexed: 01/28/2023]
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Egner W, Sargur R, Shrimpton A, York M, Green K. A 17-year experience in perioperative anaphylaxis 1998-2015: harmonizing optimal detection of mast cell mediator release. Clin Exp Allergy 2016; 46:1465-1473. [DOI: 10.1111/cea.12785] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Revised: 05/24/2016] [Accepted: 07/20/2016] [Indexed: 12/20/2022]
Affiliation(s)
- W. Egner
- Clinical Immunology and Allergy Unit and Department of Immunology and Protein Reference Unit; Sheffield Teaching Hospitals NHS Trust; Sheffield UK
| | - R. Sargur
- Clinical Immunology and Allergy Unit and Department of Immunology and Protein Reference Unit; Sheffield Teaching Hospitals NHS Trust; Sheffield UK
| | - A. Shrimpton
- Clinical Immunology and Allergy Unit and Department of Immunology and Protein Reference Unit; Sheffield Teaching Hospitals NHS Trust; Sheffield UK
| | - M. York
- Clinical Immunology and Allergy Unit and Department of Immunology and Protein Reference Unit; Sheffield Teaching Hospitals NHS Trust; Sheffield UK
| | - K. Green
- Clinical Immunology and Allergy Unit and Department of Immunology and Protein Reference Unit; Sheffield Teaching Hospitals NHS Trust; Sheffield UK
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Decuyper II, Ebo DG, Uyttebroek AP, Hagendorens MM, Faber MA, Bridts CH, De Clerck LS, Sabato V. Quantification of specific IgE antibodies in immediate drug hypersensitivity: More shortcomings than potentials? Clin Chim Acta 2016; 460:184-9. [PMID: 27376983 DOI: 10.1016/j.cca.2016.06.043] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Revised: 06/29/2016] [Accepted: 06/30/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND For many physicians, quantification of serum drug-specific IgE (sIgE) antibodies constitutes the first measure in the diagnostic approach of immediate drug hypersensitivity reactions (IDHR). AIM To review the accuracy and limitations of the main drug-sIgE tests, especially those that are commercially available. METHODS A literature search was conducted, using the key-words allergy, diagnosis, drugs, hypersensitivity, specific IgE antibodies; this was complemented by the authors' own experience. RESULTS The drugs that have mostly been studied appeared to be β-lactam antibiotics, neuromuscular blocking agents (NMBA) and morphine, the latter as a biomarker for sensitisation to substituted ammonium structures that constitute the major epitope of NMBA. For β-lactams sensitivity and specificity varied between 0-85% and 52-100%, respectively. For NMBA, sensitivity and specificity varied between 38.5-92% and 92-100%, respectively. With respect to sIgE to morphine it appears this drug to be a sensitive biomarker for sensitisation to rocuronium and suxamethonium but not for atracurium. However, sIgE morphine should not be applied in isolation to diagnose IDHR to NMBA nor opiates. CONCLUSIONS Although drug-sIgE assay can provide valuable information they should not be performed in isolation to establish correct diagnosis, as their predictive value is not per se absolute. Larger comprehensive studies are urgently required to determine the accuracy of drug-sIgE assays.
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Affiliation(s)
- I I Decuyper
- Faculty of Medicine and Health Science, Department of Immunology, Allergology, Rheumatology, University of Antwerp, Antwerp University Hospital, Belgium; Faculty of Medicine and Health Science, Department of Pediatrics, University of Antwerp, Antwerp University Hospital, Belgium
| | - D G Ebo
- Faculty of Medicine and Health Science, Department of Immunology, Allergology, Rheumatology, University of Antwerp, Antwerp University Hospital, Belgium.
| | - A P Uyttebroek
- Faculty of Medicine and Health Science, Department of Immunology, Allergology, Rheumatology, University of Antwerp, Antwerp University Hospital, Belgium
| | - M M Hagendorens
- Faculty of Medicine and Health Science, Department of Pediatrics, University of Antwerp, Antwerp University Hospital, Belgium
| | - M A Faber
- Faculty of Medicine and Health Science, Department of Immunology, Allergology, Rheumatology, University of Antwerp, Antwerp University Hospital, Belgium
| | - C H Bridts
- Faculty of Medicine and Health Science, Department of Immunology, Allergology, Rheumatology, University of Antwerp, Antwerp University Hospital, Belgium
| | - L S De Clerck
- Faculty of Medicine and Health Science, Department of Immunology, Allergology, Rheumatology, University of Antwerp, Antwerp University Hospital, Belgium
| | - V Sabato
- Faculty of Medicine and Health Science, Department of Immunology, Allergology, Rheumatology, University of Antwerp, Antwerp University Hospital, Belgium
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Kuhlen JL, Camargo CA, Balekian DS, Blumenthal KG, Guyer A, Morris T, Long A, Banerji A. Antibiotics Are the Most Commonly Identified Cause of Perioperative Hypersensitivity Reactions. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2016; 4:697-704. [PMID: 27039234 DOI: 10.1016/j.jaip.2016.02.008] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 02/15/2016] [Accepted: 02/19/2016] [Indexed: 01/13/2023]
Abstract
BACKGROUND Hypersensitivity reactions (HSRs) during the perioperative period are unpredictable and can be life threatening. Prospective studies for the evaluation of perioperative HSRs are lacking, and data on causative agents vary between different studies. OBJECTIVE The objective of this study was to prospectively determine the success of a comprehensive allergy evaluation plan for patients with HSRs during anesthesia, including identification of a causative agent and outcomes during subsequent anesthesia exposure. METHODS All patients referred for a perioperative HSR between November 2013 and March 2015, from a Boston teaching hospital, were evaluated using a standardized protocol with skin testing (ST) within 6 months of HSR. Comprehensive allergy evaluation included collection of patient information, including characteristics of HSR during anesthesia. We reviewed the results of ST and/or test doses for all potential causative medications Event-related tryptase levels were reviewed when available. RESULTS Over 17 months, 25 patients completed the comprehensive allergy evaluation. Fifty-two percent (13 of 25) were female with a median age of 52 (interquartile range 43-66) years. The most frequently observed HSR systems were cutaneous (68%), cardiovascular (64%), and pulmonary (24%). A culprit drug, defined as a positive ST, was identified in 36% (9 of 25) of patients. The most common agent identified was cefazolin (6 of 9). After our comprehensive evaluation and management plan, 7 (7 of 8, 88%) patients tolerated subsequent anesthesia. CONCLUSIONS Cefazolin was the most commonly identified cause of a perioperative HSR in our study population. Skin testing patients within 6 months of a perioperative HSR may improve the odds of finding a positive result. Tolerance of subsequent anesthesia is generally achieved in patients undergoing our comprehensive evaluation.
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Affiliation(s)
- James L Kuhlen
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass.
| | - Carlos A Camargo
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Mass
| | - Diana S Balekian
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass; Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Mass
| | - Autumn Guyer
- Division of Allergy and Inflammation, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Mass; Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California San Francisco, San Francisco, Calif
| | - Theresa Morris
- Department of Anesthesia, Massachusetts General Hospital, Boston, Mass
| | - Aidan Long
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass
| | - Aleena Banerji
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass
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Perioperative Hypersensitivity Reactions: Diagnosis, Treatment and Evaluation. CURRENT TREATMENT OPTIONS IN ALLERGY 2016. [DOI: 10.1007/s40521-016-0078-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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40
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Mangodt EA, Van Gasse AL, Bastiaensen A, Decuyper II, Uyttebroek A, Faber M, Sabato V, Bridts CH, Hagendorens MM, De Clerck LS, Ebo DG. Flow-assisted basophil activation tests in immediate drug hypersensitivity: two decades of Antwerp experience. Acta Clin Belg 2016; 71:19-25. [PMID: 27075810 DOI: 10.1080/17843286.2015.1122871] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The last two decades have witnessed that flow-assisted analysis of in vitro-activated basophils can constitute a valuable adjunct in the in vitro diagnostic approach of immediate drug hypersensitivity reactions (IDHR). This article summarises the current experience with the basophil activation test in the diagnosis of IDHR, with particular focus on allergy to curarising neuromuscular blocking agents, antibiotics (β-lactams and fluoroquinolones), iodinated radiocontrast media and opiates.
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41
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Review of Contact Urticaria Syndrome—Evaluation to Treatment. CURRENT TREATMENT OPTIONS IN ALLERGY 2015. [DOI: 10.1007/s40521-015-0068-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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42
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Krishna MT, Huissoon A. Peri-operative anaphylaxis: beyond drugs and latex. Int Arch Allergy Immunol 2015; 167:101-2. [PMID: 26278912 DOI: 10.1159/000436971] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Mamidipudi Thirumala Krishna
- Department of Allergy and Immunology, Birmingham Heartlands Hospital, Heart of England NHS Foundation Trust, Birmingham, UK
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Moka E, Argyra E, Siafaka I, Vadalouca A. Chlorhexidine: Hypersensitivity and anaphylactic reactions in the perioperative setting. J Anaesthesiol Clin Pharmacol 2015; 31:145-8. [PMID: 25948890 PMCID: PMC4411823 DOI: 10.4103/0970-9185.155138] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Eleni Moka
- Department of Anaesthesiology, Creta Interclinic Hospital, Heraklion-Crete, Greece
| | - Eriphili Argyra
- A' Anaesthesiology Clinic, Pain Relief and Palliative Care Unit, Aretaieion University Hospital, University of Athens, Athens, Greece
| | - Ioanna Siafaka
- A' Anaesthesiology Clinic, Pain Relief and Palliative Care Unit, Aretaieion University Hospital, University of Athens, Athens, Greece
| | - Athina Vadalouca
- A' Anaesthesiology Clinic, Pain Relief and Palliative Care Unit, Aretaieion University Hospital, University of Athens, Athens, Greece
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Abstract
Chlorhexidine is an antiseptic agent, commonly used, in many different preparations, and for multiple purposes. Despite its superior antimicrobial properties, chlorhexidine is a potentially allergenic substance. The following is a review of the current evidence-based knowledge of allergic reactions to chlorhexidine associated with surgical and interventional procedures.
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Affiliation(s)
- Claude Abdallah
- Division of Anesthesiology, The George Washington University Medical Center, Children's National Medical Center, Washington, D. C. 20010-2970, USA
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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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