Scandinavian Clinical Practice Guidelines on the diagnosis, management and follow-up of anaphylaxis during anaesthesia

The present approach to the diagnosis, management and follow-up of anaphylaxis during anaesthesia varies in the Scandinavian countries. The main purpose of these Scandinavian Clinical Practice Guidelines is to increase the awareness about anaphylaxis during anaesthesia amongst anaesthesiologists. It is hoped that increased focus on the subject will lead to prompt diagnosis, rapid and correct treatment, and standardised management of patients with anaphylactic reactions during anaesthesia across Scandinavia. The recommendations are based on the best available evidence in the literature, which, owing to the rare and unforeseeable nature of anaphylaxis, mainly includes case series and expert opinion (grade of evidence IV and V). These guidelines include an overview of the epidemiology of anaphylactic reactions during anaesthesia. A treatment algorithm is suggested, with emphasis on the incremental titration of adrenaline (epinephrine) and fluid therapy as first-line treatment. Recommendations for primary and secondary follow-up are given, bearing in mind that there are variations in geography and resources in the different countries. A list of National Centres from which anaesthesiologists can seek advice concerning follow-up procedures is provided. In addition, an algorithm is included with advice on how to manage patients with previous suspected anaphylaxis during anaesthesia. Lastly, Appendix 2 provides an overview of the incidence, mechanisms and possibilities for follow-up for some common drug groups.     

Anaphylaxis and anaesthesia

Editor—We read with interest the recent Editorial outliningthe current state of anaphylaxis and anaesthesia.¹ What remainsunclear is the pathophysiology behind the variability in featuresand severity of anaphylaxis under anaesthesia, and why, despitewidespread use of the Association of Anaesthetists of GreatBritain and Ireland (AAGBI) guidelines,² 10% of reactions reportedto the UK Medicines Control Agency are still fatal. It is unfortunatethat the authors of the AAGBI guidelines made no mention ofthe use of pure alpha agonists in their anaphylaxis drill forthe treatment of severe anaphylactic reactions unresponsiveto epinephrine. This was first described by Higgins and Gayatri     

Anaesthesia and the patient with latex allergy

Reports of severe life-threatening anaphylaxis to latex are increasing. A case of latex anaphylaxis occurring during surgery is reported. Sudden cardiorespiratory collapse 25 min after the start of surgery was treated with oxygen, fluid, epinephrine, hydrocortisone, and benadryl. Two months later, skin testing to latex was positive but intradermal testing to the drugs used during anaesthesia was negative. Anaesthetists should be aware of this clinical entity. Latex allergy should be considered in the differential diagnosis of intraoperative anaphylaxis. Fortunately, it is usually preventable by obtaining a positive history, recognising that it occurs in particular subsets of patients and by avoiding latex products. Skin testing to latex is available and may assist in the recognition of latex sensitivity.     

Sugammadex in the management of rocuronium-induced anaphylaxis

Anaphylaxis during anaesthesia is a rare event that in ～60-70% of cases is secondary to neuromuscular blocking agents. It has been suggested previously that the recent introduction of sugammadex may provide a novel therapeutic approach to the management of rocuronium-induced anaphylaxis. We describe the case of a 33-yr-old female who suffered a severe anaphylactic reaction to rocuronium, presenting with cardiovascular collapse on induction of anaesthesia. After 19 min of traditional management, she was given a bolus of sugammadex 500 mg. This was associated with an improvement in the adverse haemodynamic state. The underlying reasons for this are unclear, but sugammadex may potentially be a useful adjunct in the management of rocuronium-induced anaphylaxis.     

Bloc auriculoventriculaire complet peranesthésique et ischémie myocardique contemporains d’un choc anaphylactique grave

An 83-year-old man had to be operated under general anaesthesia for a head skin tumor. The preanaesthetic exam of the cardiovascular function was reassuring but a cardiac arrest with a complete heart block occurred a few minutes after induction of anaesthesia. Resuscitation managing was successful but a myocardial ischaemia appeared. Biological tests confirmed severe anaphylactic reaction. The electrocardiographic expression, pathophysiology and management of cardiac anaphylaxis are discussed.     

Anaphylaxis to cisatracurium following negative skin testing

General anaesthesia for the patient with a history of anaesthesia-related anaphylaxis is challenging. Precautions against anaphylaxis and the use of skin test negative drugs can reduce but not eliminate the risk. In the majority of such cases, subsequent anaesthesia is uneventful. However, the absence of a clearly identified triggering agent increases the difficulties facing the anaesthetist. We present a case of anaphylaxis to cisatracurium following a negative skin test.     

Outcome of repeat anaesthesia after investigation for perioperative anaphylaxis

Background

Perioperative anaphylaxis (POA) is infrequent, but remains an important and potentially life-threatening complication of general anaesthesia. The diagnostic uncertainty surrounding the investigation of anaesthetic allergy poses numerous challenges. We aimed to inform practice by auditing the outcomes of repeat anaesthesia, after an investigation for previous POA.

Cardiopulmonary distress during obstetrical anaesthesia: attempts to diagnose amniotic fluid embolism in a case series of suspected allergic anaphylaxis

BACKGROUND: Cardiopulmonary distress during obstetrical anaesthesia may result from a drug-induced allergic reaction, but, in the obstetrical setting, allergic anaphylaxis may be inseparable from amniotic fluid embolism in terms of the clinical presentation. Further investigations, using allergy tests and other laboratory analyses, are then needed to pursue a diagnostic clarification. METHODS: Twelve women suspected of having developed anaphylaxis during obstetrical anaesthesia underwent allergy follow-up investigations and further serological tests with the amniotic fluid embolism marker sialyl Tn and complement factors (C3 and C4) in an attempt to differentiate amniotic fluid embolism from drug-induced allergic anaphylaxis. RESULTS: The diagnostic programme revealed one case of probable amniotic fluid embolism and four cases of probable drug-induced allergic anaphylaxis. Of the remaining seven cases, there were two cases that, by diagnostic exclusion, could be classified as possible cases of amniotic fluid embolism. The cause of the reactions remained unresolved in five cases. CONCLUSIONS: It can be difficult to differentiate between anaphylaxis and amniotic fluid embolism, especially amongst survivors. Diagnostic markers that can be applied on peripheral blood samples are promising, but larger studies are needed to validate their use in the diagnosis of causes of cardiopulmonary distress during obstetrical anaesthesia.     

FATAL HAEMOPATHOLOGICAL CONSEQUENCES OF GENERAL ANAESTHESIA

A previously healthy 63-yr-old female died following an anaphylactoidresponse to anaesthesia with thiopentone and suxamethonium.Postmortem findings strongly suggested that disseminated intravascularcoagulation played a significant role in her death. The localmechanism behind the reaction is unknown, but the formationof thiopentone-suxamethonium colloid aggregates during induction,may have lead to "aggregate anaphylaxis".