Grades III and IV on the Ring and Messmer scale represent life-threatening perioperative immediate hypersensitivity reactions referred to as…
Perioperative anaphylaxis: Diagnosis challenged by environment/medications
Perioperative anaphylaxis is often caused by medications used in anesthesia and surgery, making diagnosis challenging due to the unique environment…
Der Anaesthesist 2020
Inject epinephrine rapidly for suspected perioperative anaphylaxis
Epinephrine should be rapidly injected for suspected perioperative anaphylaxis, alongside intravenous fluids.
Paediatric anaesthesia 2021
Pediatric perioperative anaphylaxis: Main triggers are drugs
In pediatric patients, antibiotics, neuromuscular blocking agents
IN PRACTICE
Grades III/IV are life-threatening anaphylaxis
Other · Current allergy and asthma reports
Grades III and IV on the Ring and Messmer scale represent life-threatening perioperative immediate hypersensitivity reactions referred to as anaphylaxis.
Perioperative anaphylaxis: what should be known?, Current allergy and asthma reports 2015 · PMID 26139330
IN PRACTICE
Perioperative anaphylaxis: Diagnosis challenged by environment/medications
Other · The journal of allergy and clinica
Perioperative anaphylaxis is often caused by medications used in anesthesia and surgery, making diagnosis challenging due to the unique environment and multiple substances involved.
Identification and Management of Perioperative Anaphylaxis, The journal of allergy and clinical immunology. In practice 2019 · PMID 31154032
IN PRACTICE
Inject epinephrine rapidly for suspected perioperative anaphylaxis
Other · Der Anaesthesist
Epinephrine should be rapidly injected for suspected perioperative anaphylaxis, alongside intravenous fluids.
[Management of perioperative anaphylaxis], Der Anaesthesist 2020 · PMID 32757033
IN PRACTICE
Pediatric perioperative anaphylaxis: Main triggers are drugs
Other · Paediatric anaesthesia
In pediatric patients, antibiotics, neuromuscular blocking agents, and opioid analgesics are the main triggers for perioperative anaphylaxis.
Perioperative anaphylaxis in children: A report from the Wake-Up Safe collaborative, Paediatric anaesthesia 2021 · PMID 33141983
IN THE ROOM
What this changes about the next case
Colour is the strength of the evidence behind each step, not the urgency.
1
1
Grades III and IV on the Ring and Messmer scale represent life-threatening perioperative immediate hypersensitivity reactions referred to as anaphylaxis.
2
2
Perioperative anaphylaxis is often caused by medications used in anesthesia and surgery, making diagnosis challenging due to the unique environment and multiple substances involved.
3
3
Epinephrine should be rapidly injected for suspected perioperative anaphylaxis, alongside intravenous fluids.
4
4
In pediatric patients, antibiotics, neuromuscular blocking agents, and opioid analgesics are the main triggers for perioperative anaphylaxis.
The oral-boards stem on the next slide puts these into one scenario.
KEY TAKEAWAYS
What to carry into the next case
Grades III/IV are life-threatening anaphylaxis
Current allergy and asthma reports 2015
Perioperative anaphylaxis: Diagnosis challenged by environment/medications
Inject epinephrine rapidly for suspected perioperative anaphylaxis
Der Anaesthesist 2020
Pediatric perioperative anaphylaxis: Main triggers are drugs
Paediatric anaesthesia 2021
For suspected perioperative anaphylaxis (Ring & Messmer III/IV), immediately administer epinephrine and IV fluids.
Questions I'll ask you in the room
What is the most common trigger for anaphylaxis during anesthesia?
How does the timing of onset typically differentiate between IgE-mediated and non-IgE-mediated reactions?
What hemodynamic changes are characteristic of anaphylaxis that might differ from typical anesthetic responses?
Besides epinephrine, what other immediate interventions are crucial in managing perioperative anaphylaxis?
Oral boards stem
Shortly after induction and rocuronium, the airway pressure rises sharply, the blood pressure falls to 55/30, and a rash is visible on the chest.
Board questions
1. In NAP6, the UK national audit of 266 Grade 3-5 perioperative anaphylaxis reports, what was the commonest presenting feature?
Hypotension, in 46% of cases
Bronchospasm, in 46% of cases
Urticaria or rash, in about a third of cases
Oxygen desaturation, in about a quarter of cases
Show answer
A. Hypotension, in 46% of cases
Hypotension 46%, bronchospasm 18%, tachycardia 9.8%, desaturation 4.7%, bradycardia 3%, lost capnography trace 2.3%. Every patient in the audit was hypotensive at some point during the episode. Cutaneous signs are not how this announces itself under anaesthesia.
2. Which agents accounted for most identified culprits in NAP6, and what was the estimated incidence of perioperative anaphylaxis?
Show answer
Of 199 identified culprit agents, antibiotics accounted for 94, neuromuscular blocking agents 65, chlorhexidine 18 and Patent Blue dye 9. The estimated incidence was approximately 1 in 10,000 anaesthetics, though the authors note the true incidence may be around 70% higher because of reporting delays and incomplete data.
Antibiotics were the leading identified culprit in this audit, ahead of neuromuscular blocking agents. Teicoplanin was only 12% of antibiotic exposures but caused 38% of antibiotic-induced anaphylaxis.
3. NAP6 found particular patient factors associated with poor outcome, and a characteristic cardiac arrest rhythm. What were they, and how should that change your management?
Show answer
Poor outcomes were associated with higher ASA grade, obesity, and treatment with beta blockers or ACE inhibitors. Pulseless electrical activity was the usual type of cardiac arrest, often with bradycardia, and there were 10 deaths and 40 cardiac arrests among 266 reports. The implication for management is that you should expect PEA with bradycardia rather than a shockable rhythm, and that the audit found worse outcomes among patients on beta blockers or ACE inhibitors, among those with higher ASA grade, and among those with obesity.
NAP6 reports these as associations with poor outcome, not as a tested mechanism or treatment strategy. Expect PEA with bradycardia rather than a shockable rhythm.