29/09/2016 Anaphylaxis During Surgery, Evaluation And Prevention Of Recurrence | Docplexus

AnaphylaxisDuringSurgery,EvaluationAnd

PreventionOfRecurrence
Anesthesiology PainMedicine SurgeryGeneral Sep262016
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Anaphylaxisisafatal
multisystemallergic
reaction.Theterminologyis
applicabletoboth
immunoglobulinE(IgE)
mediatedandnonIgE
mediatedreactions.Itis
veryimportanttoevaluate
patientswhohave
experiencedperioperative
anaphylacticreactionsto
preventtheirrecurrence
duringfuturesurgeries.This
articlewillprovideyou
insightsondifferent
strategiesforevaluatingand
preventinganaphylactic
reactionsduringanesthesia.

Therearetwostrategiesthat
arefollowedforthispurpose
identifyingthecausativeagent
andusingthealternative
agent.

Wewillnowgothrough
variousaspectsofevaluation
onebyone.

Historytaking:Usually
patientsareunableto
providemuch
informationregarding
allergiesencountered
duringanesthesia,however,questioningthemabouttheprioranesthesiamightbehelpfulinidentifyingprevious
exposuresandtheirmanagement.Thiscanalsobeachievedbyscanningthroughthepreviousprocedure
recordsincludingthedrugadministrationrecordsintheOT.Operativenotesmayalsoprovideagoodinsight
regardingthesame.
Testingformastcellmediators:Thelevelsofserumorplasmatryptaseand/orhistaminesaregenerally
elevatedduringofshortlyaftertheanaphylacticreactionalthoughthenormallevelsmaynotexcludethe
anaphylaxis.Thetestscanbeperformedbydrawingbloodsamplespriortosurgery.Patientswithapersistent
elevationoftryptaseabove20ng/mLshouldbeevaluatedforraredisorderssuchassystemicmastocytosis.If
thetryptaselevelsarebetween11and20ng/mL,thenthepatientsaremostlikelyatariskofdeveloping
anaphylaxisduetoamonoclonalmastcelldisorderoridiopathicmastcellactivationsyndrome.
Skintesting:Bothprickpunctureandintradermalskintestingshouldbeconsideredifthepatientisknownto
haveasusceptibilitytoIgEmediatedreactions.Skintestingismoresensitivecomparedtotheinvitrotesting.
SkintestingisusuallyadvisedforthefollowinggroupsofagentsmostoftenlinkedtotheIgEmediated
anaphylaxis:
Neuromuscularblockingagents(NMBAs)
Antibiotics,inparticular,thebetalactamantibioticssuchaspenicillinorcephalosporins

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Barbiturates
Latex
Vitaldyes(isosulfanblue)
Skintestingforstreptokinase,chymopapain,andinsulin
Forcertaindrugs,suchastheNMBAswhichareknowntobeassociatedwithanaphylaxisthrough
multiplemechanisms,skintestingforoneortwopotentialalternativedrugswhichassistsinplanningfor
futureanesthesia.Oncetheculpritdrugisidentified,thepatientshouldalsobemadeawareofthatagent
toavoidpotentiallycrossreactingdrugs.Skintestingisusuallydelayedfor4to8weeksafterthe
reactionsincethechancesoffalsenegativeresultsarehigh.Testingmaybeperformedsoonerifthereis
aneedtorepeattheanesthetic.Althoughskintestingissafeinmostofthepatients,emergency
equipmentandmedicationsincludingepinephrineshouldbekeptready.Prickpuncturetestingissafer
comparedtotheintradermalone.Ifprickpuncturetestingisnegativethentheintradermaltestingcanbe
safelyperformed.
Invitrotesting:InvitroimmunoassaysforallergenspecificIgEbyELISAmaybeusefulinidentifyingthe
causativeagentsinIgEmediatedanaphylaxis.Invitrotestingismainlyutilizedintheevaluationofpotential
reactionstolatex.AvalidatedimmunoassaytodetectlatexspecificIgEiscommerciallyavailable.

SpecificAgentsandAlternatives

NMBAs:ThemostcommonlyimplicatedNMBAsaresuccinylcholineorsuxamethonium,rocuronium,
atracurium,vecuronium,pancuronium,mivacurium,andcisatracurium.Crossreactivityhasbeendocumented
withtheuseofNMBAsandismostlyassociatedwithpancuroniumandvecuroniumandsuccinylcholineand
gallamine.Thetestingisinitiatedwithaskinpuncturetest,whichifisnegative,isfollowedbytheintradermal
testing.Arangeofconcentrationsisprovidedforsomeagentsbecauseofthevariabilityofnonirritating
concentration.IfthetestisnegativeforoneormoreoftheseagentsandasuspicionofanonIgEmediated
anaphylaxisisraised,alternativestoNMBAsareused.
Latex:AnaphylaxistolatexisanIgEmediatedprocessresultingfromtheformationofspecificIgEagainst
proteinsfromnaturalrubberlatex.ComparedwithreactionstoinductionagentsorNMBAs,latexreactionstend
tooccurlaterinprocedures.PatientswithIgEmediatedlatexallergyareusuallymanagedwithstrictlatex
avoidanceandmustundergoallfutureproceduresandsurgeriesinlatexfreeenvironments,whicharenow
availableatmosthospitals.
Antibiotics:Antibioticsarefrequentlyadministeredbefore,during,orimmediatelyafteranesthesia.Betalactam
antibioticsincludingpenicillin,cephalosporins,andvancomycinarethemostcommoncausesoftheantibiotic
inducedanaphylaxis.BetalactamantibioticscauseIgEmediatedreactionsthatcanbeevaluatedwith
appropriateskintesting.MostvancomycinreactionsarenonIgEmediatedanaphylacticreactionsrelatedtothe
rateofinfusion.Antibioticdesensitizationbytheoralrouteisassociatedwithfewerrisksthanintravenous
desensitizationandisthereforepreferredifanoralpreparationisavailable.However,sincemanyantibioticsdo
nothaveanoralformulation,antibioticdesensitizationsareoftenadministeredintravenouslyinanintensivecare
settingunderthesupervisionofanallergyspecialist.Theprocedureisusuallyaccomplishedinamatterof
hours.
Hypnoticinductionagents:Thesecontributetoabout5%ofperioperativeanaphylaxis.Twotypesofhypnotic
agentsareusedinpractice.Theyare:Barbiturates(thiopental,methohexital)andNonbarbiturates
(benzodiazepines,propofol,etomidate,andketamine).Immunologiccrossreactivityamongthebarbituratesis
possibleandskintestingisusedtoselecttheagentwhichislesslikelyassociatedwithreactions.Barbiturates
maycrossreactwithNMBAsandhencecautionisrecommendedwhileusingthesetwoclassestogether.There
isnoevidenceofcrossreactivitybetweenbarbituratesandnonbarbiturates.Thetestingisinitiatedwithaskin
puncturewithdilutedorundiluteddrugfollowedbytheintradermaltestingistheformerisnegative.Forpatients
witheitherIgEmediatedornonIgEmediatedreactionstobarbiturateagents,theuseofanonbarbiturateagent
infutureproceduresisrecommended.Desensitizationtobarbituratesistheoreticallypossiblebutnot
appropriatebecausethetimerequiredtodesensitizethepatientwouldresultinprolongedexposuretothese
agents.IncaseofanonIgEmediatedreactionandnoalternativeisavailable,thenapretreatmentwith
histaminesisrecommendedbeforeinitiatingthesameagent.
Opioids:ThesearethecommoncausesofurticariaandflushingfollowingIVorIMadministration,however,
theyrarelyarelifethreatening.Reactionstoorallyadministerednarcoticsmaybeassociatedwiththeuseof
coughsuppressantscontainingpholcodineandIgEthatcrossreactswithmorphineandNMBAs.Reactionsto
opioidsarealmostalwaysnonIgEmediated.Noskintestingisrecommendedsincenonspecificpositive
responsesareexpectedduetothenonimmunologicdegranulationofdermalmastcellswithexposuretothese
agentsornonspecificvasodilationwithtesting.Topreventtherecurringreactions,multiplepreparationsof
opioidsareavailableandrepeatexposuretotheculpritagentisrarelyrequired.Fentanylisuniqueamong
narcoticsinitslackofmastcell/basophilstimulatingproperties.Itistherefore,agoodoptionforpain
managementinpatientswhodevelopedcutaneousreactionswithothernarcotics.However,fentanylhasbeen
implicatedinanaphylaxis,albeitrarely.Asuperviseddrugchallengemaybeconsideredinpatientswhoappear
tobeverysensitivetoopioids.
NSAIDs:PatientswithpreexistingasthmaorCOPDmayhaveexacerbations,increasedupperairway
congestion,andrhinorrhea.Reactionsmayoccurwithlowdoseaspirinusedforantiplateleteffects.Thereare
noreliableskinorinvitroteststodetectNSAIDinducedexacerbations.ThebestoptionistoavoidNSAIDsin
theperioperativeperiod.
Bloodtransfusions:Administrationofbloodproductscommonintheperioperativeperiodcanresultinavariety
ofimmunologicreactionsincludinganaphylaxis.Theseincludefluidoverload,hemolyticreactions,and
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transfusionrelatedacutelunginjury(TRALI).TRALIcanmimicanaphylaxisasitresultsinacuteshortnessof
breath,hypoxemia,andhypotensionwithinonetosixhoursofatransfusion.Ithasbeenreportedtobethethird
mostcommoncauseoftransfusionassociateddeath.
Colloids:Colloidplasmaexpanders,suchasdextranorhydroxyethylstarch(HES),aresolutionsofhigh
molecularweightpolysaccharides.Anaphylaxistotheseagentsisuncommon,withreportedratesof<0.1
percentforeach.HEScanalsocausepersistentpruritusthatisrefractorytotherapyandcanlastformonths.
GelatininplasmaexpandershasbeenimplicatedinIgEmediatedanaphylaxis.Albuminhasalsobeen
implicatedinrareperioperativeanaphylacticreactions,althoughthemechanismshavenotbeenexplored.
Thereislimitedexperiencewithskintestingtocolloids.Aninvitrotestingforgelatinisavailable.
Supravitaldyes:Supravital(capableofstaininglivecells)oranilinedyes,particularlyisosulfanblueand
methyleneblue,areusedtoidentifysentinellymphnodesthatareassociatedwithspecificanatomicareaswith
confirmedorsuspectedmalignancy.Theriskofanaphylaxisisprobablysimilarwiththechemicallyrelated
supravitaldyepatentblueVandlowerwithmethyleneblue.Prickpunctureandintradermalskintestingmay
identifythecauseofprioranaphylaxisorassesssubjectsatincreasedriskforsubsequentprocedures.Patients
withhypersensitivitytoisosulfanbluecouldbeadministeredmethyleneblueorviceversa.Radioactivecolloid
maybeusedasanalternativetosentinelnodedetection,buttheinabilityofthesurgeontovisuallyconfirmthe
nodelimitsthisapproach.
Antiseptics:Chlorhexidineandbetadinearetopicalagentsusedassurgicalpreparationstoreducebacteriaon
cutaneousormucosalsurfacesthatcancauseanaphylaxis.Thelikelihoodofareactionisincreasedifthese
solutionsareappliedtoadisruptedorinjuredsurface.Thesolventfortheantisepticmayalsoinfluencethe
likelihoodofareaction,asalcoholicsolutionsofchlorhexidineareassociatedwithmorereactionsthan
chlorhexidineinothersolvents.Testingisusuallycasebased.Inpatientswithchlorhexidinesensitivity,betadine
maybeusedsincethereisnoevidenceofcrossreactivitybetweenthesetwoagents.

Thus,itisimportanttoevaluateeverypatientforanaphylacticreactionsassociatedwithanesthesiaandperioperative
drugstoavoidsevereandlifethreateningcomplicationsassociatedwithit.

Sources:

1.BrockowK.Dilemmasofallergydiagnosisinperioperativeanaphylaxis.Allergy201469:1265.
2.KannanJA,BernsteinJA.Perioperativeanaphylaxis:diagnosis,evaluation,andmanagement.ImmunolAllergy
ClinNorthAm201535:321.

Whatisyourapproachforfutureanesthesiaforpatientswiththehistoryofpreviousanaphylacticreactions?

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