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Objectives

• To emphasize the importance of not missing the diagnosis and not under-reporting the events

• To remind our department about the available anaphylaxis investigation protocol and help implement it in sites that don’t currently have it available

• To step back and analyze the efficiency of our protocol. How can we improve it?

Structure

• 2 Clinical cases• Considerations in anesthesia• Definition, clinical signs, epidemiology and

common causative agents• Diagnostic tests• New information on specific drugs• ANAPHYLAXIS INVESTIGATION - how

others do it and where we can improve

Clinical case 1

• 38 year old male

• Elective laparoscopic cholecystectomy

• GERD, mild asthma, obese

• No previous GA

• No known allergies

Clinical Case 1

• Midazolam, Fentanyl, Propofol, Lidocaine, Rocuronium, Ancef

• 5 min: profound hypotension

• No rash, no wheeze

• Good response to Epinephrine

Clinical Case 1

INVESTIGATIONS AND FOLLOW UP

Tryptase (19mcg/L)

• Allergy consult 6/52 later

• ? False positive intradermal test for Rocuronium

Clinical Case 2

• 25 year old male

• Pinning of fractured metacarpal

• Healthy

• No known allergies

• IV started

• Monitors attached

Clinical Case 2

• Sudden onset tachycardia LOC

• Pruritis

• Empty bag of Cefazolin

• Rash

• Severe hypotension

• Good response to epinephrine and IV fluid

Clinical Case 2

FOLLOW UP•Blood work according to protocol•Referral for allergy consult

RESULTS• Tryptase (46mcg/L)•No consult note on netcare

Anaphylaxis in Anesthesia - usually not a “open-and-shut case”

• multiple drugs

• common cardiovascular responses to anesthesia are also manifestations of anaphylaxis

• position changes

• insufflation

• underlying systemic disease might mask the presence of anaphylaxis

• no rash/patient covered

• delayed reactions

Anesthesia and Anaphylaxis

• anesthetic drugs

• antibiotics

• blood products

• heparin

• polypeptides (latex, protamine)

• IV volume expanders

• antiseptics (chlorhexidine and betadine)

Anaphylaxis - Definition

• Classic: Pathophysiological definition

• Now: Clinical

Any severe systemic

hypersensitivity reaction of

rapid onset, which may cause death

or other adverse outcomes• “Anaphylactoid” - outdated

Clinical manifestations of Anaphylaxis in Anesthesia

Epidemiology

• 1 in 10 000 - 20 000 anesthetic procedures

• France: 1 in 13 000, 1 in 6 500 with NMBA

• Mortality: 3.4%

• Edmonton: 31 cases over 7 years

20 000 anesthetics/year

1 in 5 000

Common causative agents

• Antibiotics• NMBA’s• Latex

• Geographical variation

Common causative agents - NMBA’s

• Reaction without previous exposure• Quaternary ammonium ions• Commonly used chemicals might sensitize

patients• Pholcodine in France and Norway• Cross-reactivity 60 - 70%

How to diagnose perioperative anaphylaxis

How to diagnose perioperative anaphylaxis

SECOND EVIDENCE (Biological)

PRIMARY investigations

- histamine

- tryptase (initial and baseline)

SECONDARY investigations

- IgE assays

How to diagnose perioperative anaphylaxis

• IgE assay specific for succinylcholine

• The other NMBA: markers with similar epitopes are used

• PAPPC vs Allergen c261 Pholcodine

How to Diagnose Anaphylaxis THE GOLD STANDARD

THIRD EVIDENCE: SKIN TESTS

• Detects IgE mediated reactions• Important tool to identify and avoid culprit substance• 6 weeks before testing• ALL drugs and substances• Positive and negative controls

Propofol and egg allergy

Propofol and egg allergy

• Retrospective chart review• 42 patients with egg allergy received Propofol• 1 allergic reaction in a boy with history of

anaphylaxis to eggs

Antibiotics and cross-reactivity

• “Penicillin allergy” is common• Cephalosporin antibiotics are popular with

surgeons• How likely is cross-reactivity?• Clinical practice based on old case reports• More recent publications

Antibiotics and Cross-reactivity

• What if my patient really needs a ß-lactam antibiotic?

• 85% of “penicillin allergic patients” have negative skin tests.

• Caution: history of anaphylaxis• Graded dose escalation

Opioids

• True allergy is rare• Side effect v.s. Pseudo-allergy v.s. Real

allergy• Cross reactivity amongst different

structural classes• Thorough allergy history before analgesic

plan

The chemical classes of Opioids

• PHENYLPIPERIDINES: miperidine, fentanyl, sufentanil, remifentanil

• DIPHENYLHEPTANES: methadone, propoxyphene

• MORPHINE GROUP: morphine, codeine, hydrocodone, oxycodone, oxymorphone, hydromorphone, nalbuphine, butorphanol, levophanol, pentazocine

Latex and food allergy

Anaphylaxis Investigation

• Australia, France and England have country wide guidelines

• Edmonton: 1 of 2 centers in Canada with a formal protocol

• No need to reinvent the wheel

• CAS for country wide guidelines

The French Guidelines

• 2005• French Society for Anesthesia and Intensive

care

French Guidelines

RESPONSIBILITIES OF THE ANESTHETIST:

• Initiate investigation

• Inform patient

• Report the event

French Guidelines: follow-up

• Written report from allergist

• Conclusion, recommendations

• Document to patient• Bracelet, medic-alert

warning

Levels of anaphylaxis follow-up1) Anesthesia

• Referral for allergy consultation - complete history is important

• Informing patient• “Allergy letter” to patient and family doc• Who should be responsible for follow-up?

Levels of anaphylaxis follow-up1) Anesthesia

STATISTICS:

• 31 cases

• 10 allergy consultations

• 6 confirmed allergies

- 3 to latex

- 2 to Ancef

- 1 to Bacitracin

Levels of anaphylaxis follow-up2) Allergologist

• Faxed consult, no closed-loop communication

• Contacting patients

• Availability of report

• Closer collaboration needed

Levels of Anaphylaxis follow-up3) The Laboratory

• Various laboratories involved

• Results hard to find

Conclusions• It is important to diagnose and follow-up

on peri-operative allergic events• Revision of current protocol and possible

nationwide guidelines would might be a realistic aim for the future

• Better collaboration between Anesthesia and Allergology is needed

• Patients need to leave the hospital with a letter and information about their potential allergy, which should be updated as information becomes available

THANK YOU & QUESTIONS

• Dr J Lujic

• Dr E Bishop

References• Levy JH, Adkinson NF. Anaphylaxis During Cardiac Surgery:

Implications for Clinicians. Anesthesia Analgesia 2008;106:392-403

• Hepner DL, Castells MC. Anaphylaxis During the Perioperative Period. Anesthesia Analgesia 2003;97:1381-95

• Murphy A, Campbell E, Baines D, Mehr S. Allergic Reactions to Propofol in Egg-Allergic Children. Society for Pediatric Anesthesia, Anesthesia Analgesia 2011;113:140-4

• Gurrieri C, Weingarten TB, Martin DP et.al. Allergic Reactions During Anesthesia at a Large United States Referral Center. Anesthesia Analg 2011;113:1202-12

• AAGBI Safety Guideline - Suspected Anaphylactic Reactions Associated with Anaesthesia. The Association of Anaesthetists of Great Britain and Ireland. July 2009

References

• Mertes PM, Laxenaire MC, Lienhart A. Reducing the risk of anaphylaxis during anaesthesia: guidelines for clinical practice. J Invest Allergol Clin Immonol 2005; Vol. 15(2): 91-101

• Dewachter P, Mouton-Faivre C, Emala CW. Anaphylaxis and Anesthesia, controversies and New Insights. Anesthesiology 2009; 111:1141-50

• Analgesic Options for Patients with Allergic-Type Opioid Reactions. Pharmacist’s Letter. February 2006 - volume 22 - Number 220201

• ImmunoCAP Allergen c261 Pholcodine. www.immunocapinvitrosight.com. April 2009

• Fisher MM, Jones K, Rose M. Follow-up after anaesthetic anaphylaxis. Acta Anaesthsiol Scand 2011;55: 99-103