Abstract

Patients with suspected peri-operative anaphylaxis (POP) require thorough investigation to identify underlying trigger(s) and enable safe anesthesia for subsequent surgery. The changing epidemiology of POP has been striking. Previous estimates of the incidence of POP have ranged between 1:6,000 and1:20,000 anesthetics, but more recent data from France and the United Kingdom suggest an estimated incidence of 1:10,000. Other important changes include a change in the hierarchy of well-recognized triggers, with antibiotics (beta-lactams) supplanting neuromuscular blockers (NMB) as the leading cause of POP. The emergence of chlorhexidine, patent blue dye, and teicoplanin as important triggers have also been noteworthy findings. The mainstay of investigation revolves around critical analysis of the time-line of events leading up to anaphylaxis coupled with judicious skin testing. Skin tests have limitations with respect to unknown predictive values for most drugs/agents and therefore, knowledge of background positivity in healthy controls, test characteristics of individual drugs and the use of non-irritant concentrations is essential to avoid both false-positive and false-negative results. Specific IgE assays for individual drugs are available only for a limited number of agents and are not a substitute for skin testing. Acute serum total tryptase has a high specificity and positive predictive value in IgE-mediated POP anaphylaxis but is limited by its moderate sensitivity and negative predictive value. Planning for safe anesthesia in this group of patients is particularly challenging and consequently anesthetists need to be alert to the possibility of repeat episodes of anaphylaxis. Because of the limitations of current investigations for POP, collecting systematic data on the outcome of repeat anesthesia is valuable in validating current investigatory approaches. This paper reviews the changing epidemiology of POP with reference to the main triggers, and the investigation and outcome of subsequent anesthesia.

Highlights

  • Peri-operative anaphylaxis (POP) is a serious and unpredictable iatrogenic adverse effect associated with substantial morbidity

  • A persistently elevated baseline tryptase (≥11.4 mcg/l) at 24 h in a patient with peri-operative anaphylaxis (POP) is a possible clue to an underlying clonal mast cell disorder [9, 13] or constitutionally elevated alpha-tryptase due to gene duplication associated with hyper alpha tryptasaemia syndrome [14]

  • Comprehensive information on optimal non-irritant concentrations for skin prick and intradermal testing is provided in a position paper by the European Network on Drug Allergy (ENDA) and the European Academy of Allergy and Clinical Immunology (EAACI) [39]

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Summary

Frontiers in Immunology

Patients with suspected peri-operative anaphylaxis (POP) require thorough investigation to identify underlying trigger(s) and enable safe anesthesia for subsequent surgery. The mainstay of investigation revolves around critical analysis of the time-line of events leading up to anaphylaxis coupled with judicious skin testing. Specific IgE assays for individual drugs are available only for a limited number of agents and are not a substitute for skin testing. Planning for safe anesthesia in this group of patients is challenging and anesthetists need to be alert to the possibility of repeat episodes of anaphylaxis. Because of the limitations of current investigations for POP, collecting systematic data on the outcome of repeat anesthesia is valuable in validating current investigatory approaches. This paper reviews the changing epidemiology of POP with reference to the main triggers, and the investigation and outcome of subsequent anesthesia

INTRODUCTION
RECOGNITION OF ANAPHYLAXIS DURING ANESTHESIA
Neuromuscular Blockers
Miscellaneous Triggers
Skin Testing
Neuromuscular blockers Antibiotics
Drug Provocation Testing
Mast cell disorders
Timing of Investigation
Findings
OUTCOME OF REPEAT ANESTHESIA
Full Text
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