麻醉中的过敏反应

过敏反应是一种严重的,能危及生命的全身高敏反应。近年来麻醉相关的过敏反应发生率正在逐渐增加。这些反应大部分是免疫介导的过敏反应（IgE介导的）或者是直接刺激组胺释放导致的类过敏反应。本文综述了麻醉相关过敏反应的机制及其危险因素、临床特点,诊断治疗及预防。     

麻醉期间的药物过敏反应

药物过敏反应在麻醉期间虽不常见，但一旦发生，反应过程有时十分凶险，甚至危及生命。现就其名称定义、分类、发病率、机制研究、诊断、临床表现、和治疗进行论述。患者接受任何物质包括药物、血制剂或乳胶者都可发生过敏反应。发病率报道不一。其发病机制与免疫系统有关。有30％～40％过敏反应无法与非免疫介导的反应区别。在围术期进行测试予以区别，病史很重要。测试方法包括血浆组胺、类胰蛋白酶和特种IgE放射免疫测定等。过敏反应犹如疾病可影响任何器官，包括全身性反应，表现为呼吸系统、心脏和皮肤等。治疗原则：早期发现和诊断，立即采取有效和合适的治疗措施，处理措施包括早期使用肾上腺素并反复使用，结果取决于反应的严重程度，用药前预防性处理尚有争议。     

顺阿曲库铵引起过敏反应的概述

背景围手术期过敏反应是全身麻醉期间严重的并发症之一,麻醉期间使用的药物均可能导致发生,其中以神经肌肉阻滞剂（neuromuscular blocking agent, NMBA）多见。目的收集国内外的相关文献,综合分析顺阿曲库铵引起过敏反应的原因、临床表现及诊断方法。内容顺阿曲库铵是和种临床上较常用的非除极NMBA,早期认为顺阿曲库铵可释放少量组胺,对循环影响较小,应用前景广泛。但在使用过程中有研究报道,顺式阿曲库铵可引起严重的过敏反应,并伴有血流动力学改变和支气管痉挛症状。趋向随着顺阿曲库铵使用率的升高。由其引起的过敏反应的发生率也随之上升,麻醉医师对此现象应加以关注和重视。     

围手术期的组胺释放

围手术期有许多因素可激发组胺释放,轻者仅有皮肤反应,重者导致呼吸循环紊乱而危及生命。及时治疗组胺引起的不良反应并设法减少其释放,对保障手术病人的安全具有重要意义。     

围术期过敏反应的研究进展

正过敏反应是指已产生免疫的机体再次接受相同抗原刺激时发生的组织损伤或功能紊乱的反应。围术期过敏反应通常为一种起病急、发展快甚至危及生命的全身或系统性的严重过敏反应~([1]),死亡率高达3%~9%~([2])。围术期过敏反应已引起麻醉医师的高度关注,本文针对围术期过敏反应的流行病学、发病机制、高危因素、预防、诊断及治疗进行综述。     

围手术期血糖控制的相关问题

高血糖可对机体产生严重不良影响,糖尿病患者手术并发症发生率和病死率明显增加．手术应激引起的高血糖和胰岛素抵抗也可产生同样不良后果．围手术期患者的代谢状态、麻醉方法、外源性葡萄糖输注、应激引起的神经内分泌反应及胰岛素抵抗等均可影响围手术期血糖的水平,且造成患者临床结局不良。严格血糖控制与降低手术后患者死亡率和并发症发生率的关系尚不明确。血糖控制对围手术期患者是必须的．但是控制的理想状态仍需要多中心临床试验证据的支持。目前普遍认为围手术期血糖控制在10mmol／L以下即可．严格血糖控制的有效性及安全性有待进一步观察。     

围手术期的抗生素应用

广义地说外科围手术期处理是一个很大的课题．其范围、期限．应理解为术前、术中和术后三方面。目前多数提到的围手术期抗生素应用,只是围绕着“做手术时候”的预防性用药,其目的主要是预防手术带来的感染,其次才是希望不发生或少发生与手术无直接关系的感染如肺炎、尿路感染等。它不包括应用于已感染、已化脓的手术,即我国传统分类中的亚类手术,后者的应用实际上已是抗生素的治疗或属抗菌疗法。近年来,已有一些单位在做这方面工作,由于种种原因．开展得不普遍。今再概括地作一介绍,期望今后有更多有关的经验积累报道。一、围手术期…     

Χ������Ѫ��������

近年来，输血的不利影响已引起人们的普遍关注。如何减少围手术期血液用量已成为提高手术麻醉质量和医院管理水平的重要标志之一。围手术期血容量保护是指在围手术期采取不同的或联合应用多种技术进行血液质和量的保护，其具体内容主要包括如下几点。     

地塞米松等药物在甲状腺功能亢进围手术期的应用及分析

目的 分析地塞米松等药物在甲状腺功能亢进（甲亢）患者围手术期的应用。方法分析198例围手术期应用地塞米松等药物的应用方法、不良反应和治疗处理。结果 本组术前应用地塞米松后，T3、FT4均较前显著下降(P＜0.05)。其中，15例出现用药后低血钾性四肢麻痹，2例出现甲亢危象前兆，9例术后出现短暂性口唇和四肢麻木，对症处...     

肝切除围手术期使用地塞米松保护肝功能的必要性及可行性研究

目的 探讨肝切除围手术期使用地塞米松保护肝功能的必要性及可行性.方法 以本科施行肝切除术的病人为研究对象,分成治疗组131例(使用地塞米松)和对照组125例(未用地塞米松),治疗组于手术当天,麻醉前静推10 mg地塞米松,术后1～3 d,每天静推10 mg地塞米松.在肝切除术前后不同时期检测血清丙氨酸转氨酶(ALT)、天门冬氨酸转氨酶(AST)、白蛋白(ALb)和总胆红素(TBIL),进行统计学分析.结果 术后1、3、7 d,治疗组的AST、ALT、TBIL均不同程度的低于对照组,术后3、7 d有统计学意义(P＜0.05).治疗组的胸水、腹水等的并发症发生率低于对照组,但无统计学意义.结论 在肝切除围手术期使用地塞米松对肝脏具有保护作用.     

Allergy and anaphylaxis in anaesthesia

Immediate hypersensitivity reactions to anaesthetic and associated agents used during the perioperative period have been reported with increasing frequency in most developed countries. Most reactions are of immunologic origin (IgE mediated, anaphylaxis) or related to direct stimulation of histamine release (anaphylactoid reactions). The incidence of anaphylaxis is estimated between 1 in 10000 and 1 in 20000 anaesthesia, and any drug administered in the perioperative period can potentially produce life-threatening immune-mediated hypersensitivity reactions. Neuromuscular blocking agents (NMBAs), latex and antibiotics represent the most frequently involved substances. However, anaphylactic reactions cannot be clinically distinguished from non-immune mediated reactions which account for 30% to 40% of hypersensitivity reactions. Therefore, any suspected anaphylactic reaction must be extensively investigated using combined peroperative and postoperative testing to confirm the nature of the reaction, the responsibility of suspected drugs and to provide precise recommendations for future anaesthetic procedures. These investigations include plasma histamine, tryptase and specific IgE concentration determination at the time of the reaction, and skin tests 6 weeks later. In addition, since no specific treatment has been shown to reliably prevent the occurrence of anaphylaxis, allergy assessment must be performed in all high-risk patients. The need for proper epidemiological studies and the relative complexity of allergy investigation should be underscored. They represent an incentive for further development of allergo-anaesthesiology clinical networks to provide expert advice for anaesthetists and allergologists.     

Allergic reactions occurring during anaesthesia

Anaphylactic reactions to anaesthetic and associated agents used during the perioperative period have been reported with increasing frequency in most developed countries. Any drug administered in the perioperative period can potentially produce life-threatening immune-mediated anaphylaxis. Most published reports on the incidence of anaphylaxis come from France, Australia, the UK and New Zealand. These reflect an active policy of systematic clinical and/or laboratory investigation of suspected immune-mediated reactions. The estimated incidence of anaphylaxis ranges from 1:10,000 to 1:20,000. Muscle relaxants (69.1%) and latex (12.1%) were the most frequently involved drugs according to the most recent French epidemiological survey. Clinical symptoms do not afford an easy distinction between immune-mediated anaphylactic reactions and anaphylactoid reactions resulting from direct non-specific histamine release. Moreover, when restricted to a single clinical symptom, anaphylaxis can easily be misdiagnosed. Pre- and postoperative investigation must be performed to confirm the nature of the reaction, the responsibility of the suspected drugs and to provide precise recommendations for future anaesthetic procedures. These include plasma histamine, tryptase and specific IgE concentration determination at the time of the reaction and at skin tests 6 weeks later. In addition, since no specific treatment has been shown reliably to prevent the occurrence of anaphylaxis, allergy assessment must be performed in all high-risk patients. Treatment of anaphylaxis is aimed at interrupting contact with the responsible antigen, inhibiting mediator production and release, and modulating the effects of released mediators. It must be initiated as quickly as possible and relies on widely accepted principles. Finally, the need for proper epidemiological studies and the relative complexity of allergy investigation should be underscored. They represent an incentive for further development of allergo-anaesthesiology clinical networks to provide expert advice for anaesthetists and allergologists.     

Role of IgE in anaphylactoid reactions during anaesthesia

As diagnostic methods of detecting drug-specific IgE antibodies become more sophisticated, the evidence implicating specific IgE in anaesthetic allergy has increased. To implicate IgE in reactions, a history resembling anaphylaxis, the demonstration of drug-specific histamine release by intradermal testing and the demonstration of specific antibodies are necessary. Such evidence is seen in 70% of muscle relaxant reactors. Basophil histamine release studies suggest that histamine release is allergen-induced, not direct, and the final evidence necessary is to demonstrate the role of drug-specific antibodies in such histamine release.     

EARLY DIAGNOSIS OF ANAPHYLACTIC REACTIONS TO NEUROMUSCULAR BLOCKING DRUGS

Neuromuscular blocking drugs (NMB) are involved in most of theanaphylactic reactions occurring during anaesthesia. Patientsare evaluated usually 6 weeks after the reaction, by skin testing.In order to obtain an earlier diagnosis, we have measured plasmaconcentrations of histamine, tryptase and NMB-specific IgE antibodiesin 14 patients after an anaphylactoid reaction. We have comparedthe results with those of skin tests and specific IgE obtained8 weeks later. Good agreement was observed in all subjects betweenthe results of skin tests and the values for histamine and tryptase,provided that both markers were measured simultaneously. Furthermore,there was no significant difference between the concentrationsof NMB-specific IgE antibodies observed at the time of the reactionand 8 weeks later. Thus anaphylaxis to neuromuscular blockingdrugs can be demonstrated at the time of the reaction by measuringplasma concentrations of histamine, tryptase and specific IgE.In the event of the patient's death, such measurements may beuseful in identifying the likely cause.     

Allergic reactions during anesthesia

Any drug or blood product administered in the perioperative period has the potential to produce a life-threatening allergic (immune reaction) called anaphylaxis. Anaphylactic reactions represent adverse reactions mediated by immunospecific antibodies (IgE and IgG) that interact with mast cells, basophils, or the complement system to liberate vasoactive mediators and recruit other inflammatory cells. Activation of humoral and cellular pathways produces characteristic responses in the respiratory (bronchospasm and upper airway edema), cardiovascular (vasodilation and increased capillary permeability), and cutaneous systems (wheal and flare). Other predictable adverse drug reactions may mimic anaphylaxis to produce similar physiologic consequences independent of allergy (immune responses). Rapid and timely cardiopulmonary intervention with airway maintenance, epinephrine, and volume expansion is essential to avoid an adverse outcome. Severe reactions may be protracted, especially during anesthesia, requiring even larger doses of catecholamines and intensive care observation.     

Anafilaxia perioperatoria severa: Incidencia en un hospital terciario en España durante 20 años. Estudio de cohorte histórico

ObjectiveTo assess the incidence of severe perioperative anaphylaxis, the mechanisms involved, the value of laboratory/skin tests, and the most effective treatments.MethodsA historical cohort study conducted in a tertiary public hospital in Spain. Patients that had undergone anaesthesia during the 20-year period were included. In these patients, 66 cases of severe anaphylaxis were found. In patients with suspicion of severe anaphylaxis, levels of blood histamine at less than 15 minutes and serum tryptase at 2, 6, and 24 hours following the reaction were determined. Skin and specific IgE tests were performed between 4 and 8 weeks later.ResultsOver the 20-year period, 288 594 anaesthetic procedures were performed. We observed cases of 66 severe anaphylaxis reaction (59% men; age, 60.8 ± 17.3 years. Symptoms observed were cardiovascular (86%), respiratory (73%), and mucocutaneous (56%). Elevated serum tryptase levels were associated with degree of severity at 2 (p < 0.0001) and 6 hours (p = 0.026) and were highest in IgE-mediated reactions (p = 0.020). All patients required treatment, and 3 events were fatal.In 84.8% of patients, skin and/or specific IgE tests were positive for antibiotics (35.8%), non-steroidal anti-inflammatory drugs (23.1%), neuromuscular blocking agents (15.4%) and latex (15.4%).ConclusionsThe incidence of severe anaphylaxis in our hospital was 1 in 4 373 anaesthetic procedures, with a death rate of 4.5%. All cases required treatment. Serum tryptase was a good predictor of reaction severity. The most frequent causative agents were antibiotics, non-steroidal anti-inflammatory drugs, neuromuscular blocking agents and latex.     

Epidemiology of anesthetic anaphylactoid reactions. Fourth multicenter survey (July 1994-December 1996)]

Since 1984 an epidemiological survey of anaphylactoid reactions occurring during anaesthesia has been obtained in France with regular repeated inquiries by the Perioperative Anaphylactoid Reactions Study Group (Gerap). The members of this group collected during the study period cases of patients having suffered from an anaphylactoid reaction and subsequently tested in their allergoanaesthetic outpatient clinic. The three previous surveys published in the Annales fran?aises d'anesthésie et de réanimation in 1990, 1993 (in English) and 1996 included 1,240, 1,585 and 1,730 patients respectively. The current survey concerned 1,648 patients, tested by the GERAP (38 diagnostic centres) from July 1994 to December 1996. The diagnostic tests for IgE anaphylaxis were cutaneous tests (prick tests and intradermal tests), which minimal dilutions for specific positive skin test were previously determined by comparison with control subjects. The cutaneous tests were performed by all the centres. These tests were associated, in 29 centres, with the detection of specific IgEs against quaternary ammonium compound and inhibition test, and detection of IgEs against propofol, thiopental and latex. Moreover, leukocyte histamine release test was performed in seven centres. The mechanism of the reaction was: anaphylaxis in 692 patients (characteristic clinical symptoms and positive allergological tests), anaphylactoid reactions in 611 patients (characteristic clinical symptoms and negative allergological tests), and other causes in 345 patients (unusual clinical symptoms and negative allergological tests). An immune mechanism was found in 53% of the reactions, with characteristic clinical symptoms occurring during anaesthesia. The 692 cases of anaphylaxis were due to 734 substances (double anaphylaxis in 42 patients): muscle relaxants (61.6%), latex (16.6%), antibiotics (8.3%), hypnotics (5.1%), colloids (3.1%), opioids (2.7%) and others (2.6%) among which aprotinin (four cases) ethylene oxide (five cases) local anaesthetics (two cases). The muscle relaxants implicated in anaphylactic reactions included: vecuronium (n = 130), atracurium (n = 107), suxamethonium (n = 106), pancuronium (n = 41), rocuronium (n = 41), mivacurium (n = 18), and gallamine (n = 9). These results reflected French anaesthetic practice, except for suxamethonium (5% of the French market share of curares). In 70% of the patients who were allergic to one muscle relaxant, cross-sensitivity was found with the other relaxants. The comparison with the three previous surveys confirms that the mechanism of about half of the anaphylatoid reactions occurring during anaesthesia is of immune origin, due to specific IgE antibodies. Muscle relaxants remain the most common cause of anaphylaxis, followed by latex whose incidence seems to decrease, whereas the incidence of anaphylaxis to antibiotics increases. Incidence of reactions to suxamethonium decreased, corresponding however to one quarter of all muscle relaxant anaphylaxis, similar with vecuronium and atracurium. For this survey, more clinical information was obtained in 583 patients, allowing the following conclusions: reactions were always more severe in case of anaphylaxis than nonspecific histamine release; reactions occurred more frequently in females (F/M = 2.5); 17% of patients allergic to a muscle relaxant were never anaesthetized beforehand; a history of reactions during previous anaesthetics was a risk factor for a reaction during subsequent anaesthetics; neither drug allergy nor atopy (except for latex allergy) were a predisposing factor for reactions with anaesthetic agents. Considering that in 1996, 8 million anaesthetics were administered in France, of which 2.5 million included the use of muscle relaxants, the overall incidence for anaphylactic reactions, all agents included, was evaluated as 1 in 13,000 anaesthetics, while the incidence of anaphylaxis to muscle relaxants was 1 in 6,500 anaesthetics.     

Anafilaxia en anestesia

This article represents the combination of expert consensus on hypersensitivity reactions of distinct international scientific societies and the experience of our unit in the diagnosis of perioperative anaphylactic reactions.The appropriate management of perioperative anaphylaxis requires early diagnostic suspicion, based on the patient's symptoms. Immediate laboratory tests (serum tryptase and plasma histamine) are required to confirm the hypersensitivity reaction but should not interfere with the start of appropriate treatment. The drug of choice in severe anaphylactic reactions continues to be adrenalin. The anesthesiologist is responsible for instigating this first phase while subsequent investigation of the causative mechanism and the etiological agent is performed by allergists. Finally, a joint report based on the findings of the (immediate and late) studies and the patient's symptoms should be provided. This report should contain information on the results of tests, the drugs and/or substances identified as causing the reaction, and recommendations for future anesthesia.     

高仿真与低仿真模拟人在围术期过敏反应模拟培训中诊疗措施学习效果比较

目的 比较高仿真和低仿真模拟人在围术期过敏反应模拟培训中诊疗措施的学习效果。方法 30名培训前从未亲历模拟演练的麻醉科住院医师参与研究,分为2组：高仿真模拟人组（HN组）和低仿真模拟人组（LN组）,每组15人。研究对象在病例演练中扮演主麻医师并作为团队的领导者,其余角色由工作人员扮演,培训导师为同一名。参与培训2周前研究对象需完成《围术期过敏反应》和《团队合作要素》视频理论学习并考核达到70分方可入组。培训病例均为过敏反应,病例剧本设置完全一致,共演练3次,每次病例结束后即时Debriefing。导师应用过敏反应病例演练评分表对研究对象第3次病例演练的表现评分。结果 HN组和LN组的过敏反应病例演练评分表得分差异无统计学意义（P>0.05）。结论 在高仿真模拟人和低仿真模拟人进行围术期过敏反应模拟培训达到类似的诊疗措施学习效果,应用低仿真模拟人能降低模拟医学培训成本,有利于在基层医院普及手术室危机事件的情景模拟教学。