anaphylaxis in general anesthesia

7/30/2019 Anaphylaxis in General Anesthesia

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Anaphylaxis in General

AnesthesiaFredric M. Hustey, MD

Associate Professor

Cleveland Clinic Lerner College of MedicineCase Western Reserve University


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Objectives

Discuss challenges in the diagnosis ofallergic reactions/anaphylaxis during general

anesthesiaList common precipitants of allergic and

anaphylactic reactions in the OR

Discuss management strategies for patientswith anesthesia induced anaphylaxis


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Not Uncommon

1/13,000 to as much as 1/3,180

mortality ranges between 3 and 9%

Moneret-Vaultrin et al. Anaphylaxis to General Anesthetics. ChemImmunology and Allergy 2010; 95:180-189.


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Mechanisms

IgE (cross-linked by allergen/drug)

Cardiovascular collapse and bronchospasmmore frequent in IgE-dependent rx

Complement activation via IgG or IgMbinding to antigen/drug

Direct complement activation via alternate

pathwayDirect activation of mast cells or basophils


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Leading Causes

Neuromuscular blocking agents (50-70% ofcases) IgE-dependent reactions predominant

Cross-reactions not uncommon

Second: latex allergy

Third: antibiotics (beta-lactams in general)

Anaphylaxis to intravenous hypnotics,plasma substitutes, aprotinin, protamineand other drugs can occur


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Diagnosis

90% of reactions appear at induction

Within seconds or minutes after IVadministration

Reactions appearing later (duringanesthesia maintenance

Latex

Volume expanders

Dyes


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Challenges in Diagnosis

Patient under general anesthesia cannotcomplain

Miss early warning signs Pruritis

Malaise

Dyspnea


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Draping

Difficult to appreciate skin manifestations suchas uriticaria


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Tachycardia, increased airway resistance,hypotension

Dose related side effects of drugs Inadequate depth of anesthesia

Surgical complications


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Clinical features can vary widely b/wpatients

May also occur in isolation Bronchospasm, hypotension with tachycardia

Mild cases (single symptom) may resolvedspontaneously without specific tx

Not recognized as allergic

Fatal re-exposure


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Most Commonly Reported Initial

FeaturesDifficulty ventilating

Desaturation

Pulselessness

Whittington et al. Anaphylactic and anaphylactoid reactions. ClinAnaesthesiol B Clin Anaesthesiol 1998; 12:301-323


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Management: Three Principles

Interrupt contact with offending agent

Modulate effect of released mediators

Inhibit further mediator production andrelease


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Primary Treatment

Cease all drugs/surgery when possible

Often difficult to identify precipitant

Multiple exposures in short timeframe

Fluids

Epinephrine


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Ring and Messmer Severity Scale

Grade I: cutaneous with or w/o angioedema

Grade II: moderate multi-organ involvement

Hypotension, tachycardia

Difficulty ventilating, bronchial hyper-reactivity

Grade III: Severe life threatening MOSinvolvement

Grade IV: Cardiac and/or respiratory arrest

Brown, SGA. Clinical features and severity grading of anaphylaxis. J AllergyClin Immunol 2004;114(2):371-376


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Epinephrine

Initial adult dosing depends on severity Grade I generally not necessary

Grade II 10-20 ug IV boluses

Grade III 100-200 ug IV boluses

Grade IV: ACLS (1mg IV bolus)

Titrate according to severity and responseRepeat q1-2 minutes as necessary

IV qtt


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Resistant to Epinephrine?

Norepinephrine qtt

Consider glucagon for patients on B-

blockers Initial dose of 3-5mg IV

*Vasopressin (2-10 unit increments IV)

*Methylene blue (inhibits NO mediation ofvascular smooth muscle relaxation)

*some data exists on these therapies but value is not

completely clear


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Secondary Treatment

Antihistamines

H1 and H2 blockers

CorticosteroidsB2 agonists for persistent bronchospasm

Observation

*Relapse can occur up to 24 hours later


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Neuromuscular Blocking Agents

Higher risk

*Succinylcholine 33.4%

*Rocuronium 29.3% *Atracurium 19.3%

*Vecuronium 10.2%

Lower risk

Pancuronium

Cisatracurium

*Mertes PM et al. Anaphylaxis during anesthesia in France: an 8 year nationalsurvey. J Allergy Clin Immunol 2011;128(2):366-373


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Can occur during first administration fromcross sensitization via similar quaternaryammonium ions

Cosmetics

Toothpastes, soaps, shampoos

Foods

Drugs (cough suppressants)


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Cross sensitization b/w NMBs is common


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Latex

Second most common cause of anaphylaxis

Risk increases with increased exposure

Health care workers Multiple surgeries

Primary cause of anaphylaxis in children subjected tomultiple surgeries (especially spina bifida)

Cross sensitization from food allergensAvocado, banana, kiwi, chestnut


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Antibiotics

Third most common etiology

Penicillins and cephalosporins account for

up to 70%Quinolones also common

Vancomycin allergy rare

Rxs related to basophil degranulation associatedwith rapid administration (red-man syndrome)


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Hypnotics

Less common

Propofol in patients with egg/soy allergy

Insufficient evidenceMidazolam, etomidate, ketamine

Rare

Isoflurane, desflurane, sevoflurane Exceedingly rare


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Colloids

All can precipitate but low incidence (.03-.2%)

Gelatins and dextrans > Albumin orhetastarch


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Post Anaphylaxis Analysis

Challenges

Was this a true allergic response?

What was the precipitating agent?


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Was This a True Allergic Response?

Analyze the clinical data (hx, timing, sxs,response to tx)

Serum markers of mast cell activation canbe sent intraoperatively

Triptase levels within 30-120 minutes ofsymptom onset

Serum histamine degraded quickly and may notbe reliable


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What was the Precipitating Agent?

Immunological assessment of suspectedallergen should be based on more than onetest

Avoid single test - no test is perfect

False positives exclude otherwise useful agent

False negatives can result in potential fatal re-

exposure


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Referral for Allergy/Immunology testing

Quantification of specific IgE (best during thefirst 6 months after the event)

Skin testing (best within the first year after theevent)

Other biologic assays


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AVOID RE-EXPOSURE


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Conclusion

Anaphylaxis in general anesthesia is rarebut life threatening

Diagnosis can be challenging in the ORenvironment

Early recognition and management is criticalto prevent morbidity and mortality


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Questions?

anaphylaxis in general anesthesia

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