Rezidivierende Ergussbildung und granulomatöse Synovitis nach Knietotalendoprothesenimplantation bei Latexallergie

An increasing number of articles report about allergic reactions in association with total knee arthroplasty. While most studies focus on allergic reactions to metallic components, few reports exist about reactions to bone cement or its ingredients. Allergy to natural rubber latex is a major occupational problem in the health care sector and a problem even in other occupations in which protective gloves are used. The allergic reaction to latex ranges from a minor skin rash to anaphylactic shock. Preventing exposure to latex is the key to managing and preventing this allergy. We report about a patient who developed recurrent effusion and granulomatous synovitis following total knee arthroplasty in association with latex allergy.     

Characteristics of anaphylactic reactions to antibiotics administered under anesthesia]

Wide application of active chemical and biological substances in medical practice is inevitably associated with the appearance of adverse side reactions sometimes hazardous for patients' life. Especially grave allergic reactions are observed to antibiotics administered under narcosis. Narcosis would inhibit an anaphylactic response, but with its cessation when the allergen concentration in blood is high enough an extremely rapid anaphylactic reaction would develop that promptly resulted in a terminal patients' condition. Three case reports are described. Reanimation measures proved to be a success only in 2 cases.     

Deux cas d'anaphylaxie au dropéridol

Following two cases of anaphylactoid reactions during anaesthesia, immunoallergological investigations showed up the responsability of droperidol, which probably acted by way of an anaphylactic mechanism. In both cases, there were no cardiovascular signs, the main clinical symptom being bronchospasm. The exceptional nature of allergic accidents due to neuroleptic drugs, as opposed to extrapyramidal phenomena, must be underlined. However, these reactions should cast doubts on the safety and usefulness of neuroleptanalgesia.     

Anaphylaxis to benzalkonium chloride-coated central venous catheter

Benzalkonium chloride (BAC) is commonly used as a bactericidal preservative and it may cause allergic reactions in some patients. An unusual case of anaphylactic shock in a 55-year-old woman following insertion of a central venous catheter (CVC) that was coated with BAC is presented. Assuming anaphylactic shock from the CVC, the catheter was removed immediately. Standard resuscitation was started with 100% oxygen, epinephrine, and saline infusion. The patient recovered without any sequelae. One month later, an intradermal skin test was positive for BAC.     

Use of prophylactic combined H1 and H2 antagonists reduces mortality in chymopapain anaphylaxis

The American experience concerning the epidemiology of anaphylactic reactions following chemonucleolysis with chymopapain (Chymodiactin) were presented. The first study involved 1,585 patients of whom 17% were premedicated with some drug with either an H1 or H2 antagonist or both. The rate of anaphylaxis was 0.82%. Following its clinical introduction, a postmarketing surveillance study was undertaken. During the first 30,000 cases of which 93% were premedicated with combined H1 and H2 antagonists, the frequency of anaphylactic reactions was 0.78%. Subsequently, following the introduction of an immunologic test to screen for circulating IgE, the reaction rate fell to 0.44% in 45,000 cases of which 92% were premedicated with combined H1 and H2 antagonists. Females were far more likely to experience an anaphylactic event. Overall mortality from anaphylaxis decreased from one in 800 to one in 25,000 administrations. The decreased number and severity of these reactions correspond to the development of an immunologic screening test and utilization of prophylactic antihistamines.     

Shock anafiláctico versus síndrome de Kounis durante el intraoperatorio de cirugía cardiaca: diagnóstico diferencial

Although Kounis syndrome was described almost 3 decades ago, there has been a notable increase in the reports of cases of acute coronary syndromes developed in the context of allergic reactions, also known as Kounis syndrome. This article discusses the diagnostic possibility in the face of an acute biventricular failure in the course of an anaphylactic reaction during the intra-operative period of a cardiac valve surgery.     

Immunological reactions in acute destructive pneumonia in children

Clinical examinations of 512 children with acute destructive pneumonia have shown high incidence (27.1%) of medicamentous allergic reactions, high level of sensibilization to antigens of the lung tissue. The use of small doses of polyglucin in experiment prevents the appearance of anaphylactic shock, and in patients with a destructive pneumonia it made the incidence of medicamentous allergic reactions 7 times less frequent.     

Anaphylactic shock during general anaesthesia due to fentanyl and alloferin in a patient with positive skin test (author's transl)

A patient who suffered an anaphylactic shock during general anaesthesia showed positive reactions in a skin test with fentanyl (i.e. in Thalamonal) and Alloferin. As we did not find similar case reports in literature we present this rare case of anaphylactic shock during general anaesthesia evidently based on allergic mechanisms induced by fentanyl and Alloferin.     

Preoperative evaluation of patients with history of allergy

The prevalence of allergic reactions in general opulation shows a constant rise. It has been estimated that up to 40% of surgical patients have a positive history of some kind of allergy. These patients represent a challenge during perioperative evaluation, since they can be exposed to a large variety of drugs and substances during surgery and anesthesia. A lot of adverse drug reactions show similar clinical presentation with allergic reactions. The latter are usually poorly explored since preoperative allergology testing is performed in a limited number of patients. Management of patients with history of allergy is impeded by the fact that most of allergens cross-react in a manner that is not always easy to predict. Allergies can manifest themselves with a broad spectrum of clinical symptoms, ranging from mild skin symptoms such as itch and urticaria, to a life-threatening anaphylactic reactions followed by hypotension, bronchospasm and cardiovascular collapse. Prevention of allergic reactions during perioperative period requires detailed history taking in order to identify patients at risk, optimization of anesthesia strategy, pharmacological premedication and further allergology diagnostic work-up in selected cases.     

CROSS-REACTIVITY OF METOCURINE, ATRACURIUM, VECURONIUM AND FAZADINIUM WITH IgE ANTIBODIES FROM PATIENTS UNEXPOSED TO THESE DRUGS BUT ALLERGIC TO OTHER MYONEURAL BLOCKING DRUGS

An inhibition assay was used to determine quantitatively theallergenic cross-reactivity of some myoneural blocking drugsnot yet released for use in Australia, in the sera of patientswho had experienced anaphylactic reactions to neuromuscularblocking drugs. Two of the compounds, metocurine and atracuriumwere highly cross-reactive with the currently used myoneuralblockers; fazadinium was weakly cross-reactive and vecuroniumintermediate in potency between these two extremes. From theseresults, we predict that anaphylactic reactions to these compounds,and particularly to metocurine and atracurium, will occur insome patients allergic to the currently used neuromuscular blockingagents.     

Anaphylaxis to Haemaccel and cross reactivity to Gelofusin

A recent change from Haemaccel to Gelofusin as the preferred colloid for resuscitation in our region caused us to review patients who were known to be allergic to Haemaccel. As Gelofusin and Haemaccel are both modified gelatine, it seemed likely that cross reactivity could occur. Two patients who had been diagnosed previously as having had anaphylactic reactions to Haemaccel were tested intradermally with dilutions of 1/100 of Haemaccel and Gelofusin. Both patients showed similar positive reactions to each agent. It appears that patients who are known to be allergic to Haemaccel are probably allergic also to Gelofusin. Both patients have been given new Medic Alert bracelets stating "Allergic to Haemaccel and Gelofusin".     

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。     

Schwere Anaphylaxie nach Rocuronium

Muscle relaxant drugs are the most frequent cause of anaphylactic and anaphylactoid reactions during anaesthesia. We report a case of a life-threatening anaphylactic reaction during induction of anaesthesia with severe bronchospasm as the first clinical symptom. Mechanical ventilation was nearly impossible. The patient required a multimodal antiallergic therapy and a high-dose catecholamine therapy for stabilization. Rocuronium was identified as the allergic agent using intradermal testing.     

Intraoperative anaphylaxis in a patient with undiagnosed latex sensitivity

Latex allergy is a cause of anaphylactic reactions during general anesthesia. It is currently the second most common cause of anaphylaxis during anesthesia and should be considered in all cases in which signs develop during surgery. Clinical manifestations are highly variable and depend on the type and amount of exposure to the allergen as well as on individual sensitivity. Cardiovascular collapse is the most common presentation in anesthetized patients, and the second most common manifestations are skin rash and bronchospasm. Latex gloves are implicated in most allergic reactions triggered by latex. Individuals allergic to latex are also sensitive to certain fruits (latex-fruit syndrome) because the presence of specific proteins common in both causes a phenomenon known as cross reactivity. A 34-year-old man with acute abdomen underwent emergency exploratory laparoscopy, which was converted to laparotomy based on findings in the surgical field. Coinciding with surgical manipulation, the patient developed severe hypotension, tachycardia, bronchospasm, and arterial desaturation, which responded favorably to intravenous fluids and medication. After all other possible causes of the events were ruled out, intraoperative anaphylactic reaction was suspected and later confirmed by tests, including allergy tests. When the patient was stable and the surgical environment was latex-free, the procedure was carried out with no complications and the postoperative course was uneventful.     

Anästhesiologische Besonderheiten bei Patienten mit Latexallergie

Immediate-type hypersensitivity due to natural rubber (latex) products is an increasing problem for the anaesthetist, because a major part of products used for anaesthesia contains natural rubber. If the patient has a positive history of allergic symptoms after contact to natural rubber like urticaria, bronchospasm or anaphylaxis, preoperative skin tests, in vitro-tests, and if necessary even latex-glove wearing-test should be performed. If preoperative diagnosis of natural latex allergy is established, latex free anaesthesia is strictly recommended, otherwise life-threatening complications may ensue. Accordingly, we report on a patient who developed intraoperative anaphylactic shock following exposure to natural latex. In addition to the treatment with drugs, latex-containing products should be immediately replaced by latex free ones, in particular all persons should put on latexfree gloves. For prevention of anaphylactic episodes in sensitized patients the reader is provided an examplary list of latexfree products for anaesthesia. Because the incidence of immediate-type reactions to latex is still increasing, intraoperative occurence of an anaphylactic reaction to an unknown agent is likely to be due to allergy to natural rubber.     

Anaphylaxis following prophylactic i.v. cephradine in an orthopaedic patient

Cephradine is the most commonly used antibiotic for prophylaxis in orthopaedic patients as it is safe and effective. We report a case of severe anaphylactic reaction to cephradine in an elderly patient who had no history of allergic reactions to any drugs until then.     

Cephalosporins Can Be Given to Penicillin-allergic Patients Who Do Not Exhibit an Anaphylactic Response

Study Objectives: To assess the risk of intraoperative allergic reactions to cephalosporins in patients who claim to be allergic to penicillin.

Design: Retrospective chart review.

Setting: University-affiliated hospital.

Measurements: 2,933 intraoperative anesthesia records of all adult orthopedic patients treated at our institution during a 14-month period (7/96–8/97) were reviewed for antibiotic use and allergic reactions.

Main Results: Most of the 2,933 orthopedic patients, including 413 patients who were allergic to penicillin, received a cephalosporin (usually cefazolin) during their procedure. Only one of the penicillin-allergic patients may have had an allergic reaction to the cephalosporin, because diphenhydramine and hydrocortisone were given at the beginning of the case. However, no mention was made on the chart about itching or a rash or hives. One of the non-penicillin-allergic patients did develop a rash while the cephalosporin was infusing, requiring discontinuation of the antibiotic.

Conclusions: Given the low incidence of allergic reactions, it appears to be safe to administer cephalosporins to patients who claim to be allergic to penicillin. However, no conclusion can be made concerning patients who report severe or anaphylactic reactions to penicillin, because these patients probably were excluded from the study.     

Anaesthesia for the allergic patient

Knowing that allergic reactions that occur during anaesthesia are essentially caused by muscle relaxants or latex, the patients who should be singled out during the preanaesthetic visit are those already allergic or thought to be allergic to these two substances. On the other hand, atopy or allergy to other drugs, such as antibiotics, has not been proved to favour the triggering of anaphylactic shocks with anaesthetic drugs. Allergy to local anaesthetics is so exceptional that it may be easily dismissed by a challenge test.     

A Rapid Increase in Foot Tissue Temperature Predicts Cardiovascular Collapse during Anaphylactic and Anaphylactoid Reactions

Background: Cardiovascular collapse during anaphylactic and anaphylactoid reactions results from release of histamine and other vasoactive substances. Intense arteriolar vasodilation associated with severe allergic reactions is likely to increase convective transfer of heat and peripheral tissue temperature, and finally to provoke cardiovascular collapse. Therefore the authors tested the hypothesis that during anaphylactic and anaphylactoid reactions, an acute increase in peripheral tissue temperature precedes cardiovascular collapse and that the magnitude of the increase correlates with the severity of the reaction.

Methods: During a 13-yr period, approximately 120,000 patients were screened for clinical evidence of intraoperative anaphylactic and anaphylactoid reactions. Core temperature was measured in the distal esophagus, and "deep" foot tissue temperature was measured on the sole of one foot in all these patients. Otherwise unexplained cardiovascular collapse accompanied by bronchospasm and/or cutaneous signs such as urticaria, flushing, or angioedema occurred in 32 patients who were entered into a prospective diagnostic protocol. Among these, 15 met laboratory criteria for anaphylactic or anaphylactoid reactions. Anaphylaxis was confirmed in nine of them by a positive skin test to the suspected agent, the in vitro leukocyte histamine-release test, or the Praunitz-Kustner test. Reactions were considered anaphylactoid in six others when laboratory evidence did not support anaphylaxis, but plasma histamine or tryptase concentrations were much greater during episodes than 6 weeks later.

Results: Development of anaphylactic and anaphylactoid reactions followed a characteristic pattern: (1) Foot temperature, which was initially 3.3 +/- 1.7 [degree sign] Celsius less than core temperature, increased to within 0.3 [degree sign] Celsius of core temperature 3.2 +/- 1.4 min after drug administration; (2) onset of cardiovascular collapse ensued 1.8 +/- 0.8 min later; and (3) core temperature increased from 34.7 +/- 1.0 [degree sign] Celsius to peak values 37.1 +/- 0.6 [degree sign] Celsius 13 +/- 5 min after drug administration. The most severe reactions were associated with shorter times to comparable core and foot temperatures, faster onset of cardiovascular collapse, and higher maximum core temperatures.     

围手术期地塞米松过敏的研究进展

围手术期地塞米松常应用于抗过敏治疗,近年来关于地塞米松引起的过敏反应的报道也越来越多。这些反映主要包括IgE介导的过敏反应和药物直接刺激释放组胺引起的类过敏反应。地塞米松引起的过敏反应是一种全身性或系统性反应．症状可从局部至全身。围手术期过敏原检测起着重要的作用．这些检测方法包括皮肤过敏试验．血清中组胺、类胰蛋白酶和IgE抗体浓度检测等。另外过敏反应发生后及时供氧、扩容和肾上腺素的应用是抢救患者的关键。