The Journal of Allergy and Clinical Immunology: In Practice
Review and Feature ArticleCurrent Knowledge and Management of Hypersensitivity to Perioperative Drugs and Radiocontrast Media
Section snippets
Epidemiology of Perioperative Anaphylaxis
The incidence of anaphylaxis during general anesthesia is approximately 1:2,000 to 1:20,000 from different countries.1, 2, 3, 4, 5, 6, 7, 8 The variability in estimates of incidence and prevalence reflects difficulties in determining the total number of anesthesia cases. Perioperative anaphylaxis occurs equally in girls and boys. It is more common in adult women compared with men. The proportion of IgE-mediated allergic reactions seems to be similar between countries, around 60% of all allergic
Etiologies of Perioperative Anaphylaxis
Penicillins and cephalosporins account for most perioperative cases of anaphylaxis in the United States.8, 9, 13 Those patients with IgE-mediated allergy to penicillins may be reactive to the beta-lactam ring structure that is common to all penicillins, except in the case of amoxicillin, where the likely culprit is the side chain. In the United States, most penicillin-allergic patients are sensitive to the beta-lactam core. It has been stated that the risk of cephalosporin cross-sensitivity in
Clinical Presentation of Perioperative Anaphylaxis
Perioperative anaphylaxis usually occurs within minutes of anesthetic induction. Cardiovascular and respiratory compromise are the hallmarks of perioperative anaphylaxis.44 Cardiovascular collapse may be the first detected manifestation in up to 50% of the cases.13 Cutaneous symptoms may be absent or may not be visible due to surgical drapes. Typically, the initial diagnosis is based on the timing of the suspected trigger and the onset of clinical symptoms.
The clinical diagnosis is presumptive.
Mechanisms
Anaphylaxis is an acute, potentially fatal syndrome affecting multiple organs, resulting from the sudden release of mast-cell and basophil-derived mediators into the circulation.53 The mechanisms include IgE-dependent mechanisms, non–IgE-mediated immunologic mechanisms (previously called anaphylactoid), and direct release of histamine and other mediators from mast cells and basophils, complement activation, and kallikrein activation. Non–IgE-mediated anaphylaxis can clinically present like an
Management
One of the cornerstones in the treatment of perioperative anaphylaxis is aggressive fluid therapy. Fluid therapy is required to compensate for the peripheral vasodilation and the strong interstitial capillary leakage that occurs during anaphylaxis. The best treatment for the paradoxical bradycardia is fluid therapy. It would be dangerous to give an anticholinergic, as this bradycardia is an adaptive life-saving mechanism to allow the ventricles to fill. There is no randomized study comparing
Testing
The evaluation usually starts with reviewing the clinical history, anesthesia records, nursing records, and operative/procedural reports. Skin testing remains the best way to identify the likely agent and also help provide alternative drugs. Skin testing is more sensitive than in vitro testing, in most cases.
A total serum tryptase concentration can be measured between 1 and 4 hours after the event. It typically reaches a peak within 15 and 120 minutes. Tryptase's half-life is 120 minutes and
Options for Retreatment
Patients with IgE-mediated reactions to antibiotics are generally managed by avoiding the culprit antibiotic and an alternative antibiotic is used. Vancomycin reactions are rarely IgE mediated and can be given with antihistamine premedication and slower rates of infusion.
For patients with a reaction to NMBA, it is recommended to use an alternative agent. We often will skin test to at least a couple of NMBA alternatives and use one that was skin test negative. Desensitization to NMBA is not
Conclusions
Perioperative anaphylaxis is rare, but can be fatal. It is usually rapid and with an unexpected onset in the operating room. Fluid resuscitation and epinephrine are key to treatment. Drawing a serum tryptase is recommended to confirm anaphylaxis. Allergy investigations to identify the culprit are important, so the patient can undergo the needed procedure. In the United States, antibiotics are the most common etiology. In Europe, anaphylaxis to NMBAs is common. Chlorhexidine and blue dye allergy
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Association Between Early Patient Characteristics and IgE-Mediated Allergy in the Perioperative Setting
2024, Journal of Allergy and Clinical Immunology: In PracticePerioperative Anaphylaxis
2022, Immunology and Allergy Clinics of North AmericaCitation Excerpt :Possible contributors include the female hormones’ influence on the type 1 helper T-cell/type 2 helper T-cell balance or the propensity for female patients to be sensitized to NMBAs through common consumer products.18 POA carries a higher mortality rate than other causes of anaphylaxis, with estimates ranging from 1.4% to 9%.1,19 Approximately 60% of POA episodes are determined to be IgE-mediated, with the remainder due to a nonidentified allergen or non-IgE mechanisms, such as direct mast cell mediator release, kinin system modulation, nonspecific complement activation, and drug-bound IgG interaction with FcγR-expressing neutrophils, macrophages, or platelets.20–22
Recurrent immediate hypersensitivity reaction to radiocontrast media despite premedication found to be IgE-mediated
2020, Annals of Allergy, Asthma and ImmunologyThe Journal of Allergy and Clinical Immunology: In Practice 2017 Year in Review
2018, Journal of Allergy and Clinical Immunology: In PracticeCitation Excerpt :Many 2017 In Practice articles addressed this important topic by providing new information regarding allergy to specific drugs and drug classes, diagnostic techniques, and management beyond avoidance. A highlight of the 2017 drug hypersensitivity resources in the journal was the May/June theme issue, which provided comprehensive reviews on hypersensitivity to aspirin and other NSAIDs,236 progestogens,237 antibiotics,238 perioperative drugs and radiocontrast media,239 chemotherapeutic agents,240 and monoclonal antibodies.241 The theme issue also provided very valuable reviews of severe delayed cutaneous and systemic reactions to drugs242 and cardiovascular and diabetic medications that cause bradykinin-mediated angioedema.243
Chronic Allergic Contact Dermatitis Due to Chlorhexidine
2018, Journal of Allergy and Clinical Immunology: In PracticeDrug-Induced Anaphylaxis
2017, Immunology and Allergy Clinics of North AmericaCitation Excerpt :In case of radiocontrast media hypersensitivity, patients with a history of immediate reactions should receive corticosteroid and antihistamine premedication before re-exposure. Because IgE-mediated anaphylaxis to radiocontrast media is rare, there is a universal consensus that routinely skin testing for all patients with a past reaction is not effective.60 In some cases, there is no alternative drug to treat a patient's condition instead of the drug imputed in the HSR.61
No funding was received for this work.
Conflicts of interest: K. S. Hsu Blatman is employed by the Brigham and Women's Hospital. D. L. Hepner serves as an editor for UpToDate.