Life-threatening anaphylactoid reactions to propofol (Diprivan)

Fourteen patients who had had a life-threatening reaction within a few minutes after receiving propofol (Diprivan) were investigated for anaphylaxis 4-6 weeks after the incident. Three kinds of immunologic tests were carried out: skin tests (prick tests and intradermal tests with the drugs used and Intralipid, the solvent for propofol), a leukocyte histamine release test, and a radioimmunoassay (RIA) of immunoglobulin E (IgE) against propofol and muscle relaxants, when they had been given with propofol. It had been previously shown that these were always negative in patients anesthetized with propofol without any complications. Thirteen of the 14 patients had at least one positive test supporting hypersensitivity to propofol; 2 patients had three tests positive; 4 had two tests positive; and 7 had one test positive. The skin tests with Intralipid were negative in 4 patients whose tests with propofol were positive. Two patients who had been given muscle relaxants at the same time as the propofol had positive IgE-RIA to both drugs. In one patient, results of all the tests remained negative, and the mechanism involved in the reaction remained unidentified. It is note-worthy that 9 patients of 14 had allergic histories that were known before the anesthetic (atopy; allergy to antibiotics, muscle relaxants, lidocaine, colloids) and that none of the patients had ever received propofol or Intralipid before. It is possible that the IgE that linked abnormally with the propofol had specific binding sites for the phenyl nucleus and the isopropyl groups, which are present in propofol and many other drugs.(ABSTRACT TRUNCATED AT 250 WORDS)     

Risk factors in anaphylactoid reactions to muscle relaxants. A retrospective study of 103 cases of shock

A homogeneous series of 103 cases of shock due to muscle relaxants has been used to identify the risk factors in anaphylactoid shocks due to either true anaphylaxis or to non-specific histamine release. Clinical atopy (asthma) and sub-clinical atopy as shown up by skin tests with mites and pollens, as well as a history of IgE-dependent drug allergy, were present with a significantly greater frequency in the history of patients presenting with anaphylaxis. Abnormal histamine release and reactivity to histamine, as assessed by skin tests with 48/80 and histamine, were often found in those patients who presented with non-specific histamine release induced by muscle relaxants. Whatever the mechanism for the shock, the frequency of spasmophilia was increased. A history of non-immunological intolerance to acetyl salicylic acid and other non-steroid anti-inflammatory drugs was more often found than in the reference drugs was more often found than in the reference population. However, 25% of the patients studied did not have any of these risk factors. Several possibilities of preventing anaphylactoid reactions are given, if one or more of these risk factors are found in the history: a better choice of anaesthetic drugs, in the light of previous anaesthetic protocols, the relief of anxiety by appropriate premedication, antihistamine premedication and the prevention of bronchospasm.     

Life-threatening anaphylactoid reaction following etomidate

In a patient scheduled for coronary artery bypass grafting induction of anaesthesia resulted in a life-threatening anaphylactoid reaction with development of an erythema of the neck. Severity and duration of hypotension and tachycardia were such as to require intensive management and postponement of surgery. Skin tests ruled out any other cause except etomidate. Hence for definite surgery exactly the same induction manoeuvre was chosen, but etomidate was omitted. Anaesthesia and surgery proceeded completely uneventfully. There can be no doubt that this anaphylactoid reaction (grade III according to the classification proposed by Lorenz and Doenicke) was caused by etomidate.     

Life-threatening anaphylactoid reaction associated with indigo carmine intravenous injection

Indigo carmine (sodium indigotindisulfonate), a blue dye, has been widely used by surgeons to identify and to examine the urinary tract and is considered biologically inert and extremely safe. We present a case of severe life-threatening anaphylactoid reaction followed by cardiac arrest associated with intravenous indigo carmine injection.     

Anaphylactic and anaphylactoid reactions

Anaphylactic and anaphylactoid reactions are an important area of anaesthesia and critical care medicine. Clinically they may be indistinguishable, and the immediate management for both conditions is identical. Immediate recognition and appropriate management are vital to prevent death. The aims of testing are to confirm an anaphylactic or anaphylactoid reaction, to identify the causative agent and to test for cross-reactivity with other related agents. Testing is complex and should be supervised by a clinical immunologist.     

Anaphylactic and anaphylactoid reactions to intravenous anesthetic agents

A brief review of anaphylactic and anaphylactoid reactions to some i.v. anaesthetic agents is presented. Etiology, mechanisms, preventive aspects and treatment are discussed.     

Intradermal testing and anaphylactoid reactions

A patient who exhibited a severe reaction to an intravenous agent on one occasion was given a similar anaesthetic on a subsequent occasion without incident. Intradermal testing was carried out and the results are tabulated and discussed.     

Management of acute anaphylactoid reactions

It must be emphasized that successful treatment of a severe anaphylactoid reaction requires rapid diagnosis and initiation of the resuscitation ABC. Intravenous volume infusion and epinephrine are the mainstays of treatment, and antihistamines are useful. Bronchospasm and persistent hypotension will require specific measures, and the overall intensity of treatment needs to be frequently and critically assessed. Identification of the offending drug and appropriate patient follow-up are essential sequelae of successful resuscitation.     

Acute anaphylactoid reactions in hemodialysis

Our recent experience with membrane reactions in three hemodialysis patients is reported. We believe that two distinct populations manifest this reaction. First, well-known chronic hemodialysis patients may be exposed to inadequately rinsed new membranes. The etiology may be related to ethylene oxide either as a direct toxin or as a hapten attached to serum proteins. Adequate attention to dialysis membrane priming should eliminate this particular reaction. In the second group, the patients are new to the unit (transients) and frequently arrive with little information on prior care. Two of our patients and at least one other in the literature demonstrate markedly elevated IgE levels. This suggests an IgE-mediated mechanism; whether this is related to the membrane type, ethylene oxide, or a currently undetermined allergen remains uncertain.