Cause Of Perioperative Anaphylaxis Research Articles

Basophil activation test in the diagnostic workup of perioperative anaphylaxis due to neuromuscular blocking agents: A case series and implications for practice.

In Australia, neuromuscular blocking agents are the leading cause of perioperative anaphylaxis. Current investigation of suspected anaphylaxis includes tryptase levels, serum immunoglobulin E (IgE) levels, and skin testing, including intradermal testing and skin prick testing. The gold standard for the diagnosis of a hypersensitivity reaction is a challenge test, but this poses a risk to patient safety. An alternative test, known as the basophil activation test (BAT) is a form of cellular in vitro testing using flow cytometry to measure the degree of basophil degranulation within a sample of blood following exposure to an allergen. This acts as a surrogate marker for mast cell and basophil activation, thereby identifying IgE-mediated allergy. It is most commonly used to supplement equivocal findings from initial in vitro testing to assist in confirming the diagnosis of a hypersensitivity reaction and identify the causative agent. We present a case series in which five patients with suspected anaphylaxis underwent a BAT, demonstrating its role and limitations in allergy testing within Australia.

Epidemiology of perioperative anaphylaxis in France in 2017–2018: the 11th GERAP survey

BackgroundPerioperative anaphylaxis is rare but is associated with significant morbidity. This complication has been well described in France by the GERAP (Groupe d'Etude des Réactions Anaphylactiques Périopératoires), a network focused on its study. The epidemiology of perioperative anaphylaxis is evolving, influenced by environmental factors and clinical practice. The aim of this study was to update the epidemiology of perioperative anaphylaxis in France. MethodsThis multicentre retrospective study was performed in 26 allergy clinics of the GERAP network in 2017–8. ResultsThere were 765 patients with perioperative anaphylaxis included. Most cases were severe, with 428 (56%) reactions graded as 3 or 4 according to the Ring and Messmer classification. Skin test results were available for 676 patients, with a culprit agent identified in 471 cases (70%). Neuromuscular blocking agents were the main cause of perioperative anaphylaxis (n=281; 60%), followed by antibiotics (n=118; 25%) and patent blue dye (n=11; 2%). Cefazolin was the main antibiotic responsible for perioperative anaphylaxis (52% of antibiotic-related reactions). Suxamethonium and rocuronium were the main neuromuscular blocking agents responsible for perioperative anaphylaxis with 7.1 (6.1–8.4) and 5.6 (4.2–7.4) reactions per 100,000 vials sold, respectively, whereas cefazolin-related cases were estimated at 0.7 (0.5–0.9) reactions per 100,000 vials sold. ConclusionsOur results confirm that most commonly identified triggering agents remain neuromuscular blocking agents. Reactions to antibiotics, particularly cefazolin, are becoming increasingly frequent. The origin of sensitisation to cefazolin is unknown, as no cross-sensitisation has been described, and it should be the subject of further study. Perioperative anaphylaxis should be followed over the years and understood given the changing triggers. Clinical trial registrationClinicalTrials.gov (NCT 04654923).

Neuromuscular blocking agent re-exposure in a retrospective cohort with neuromuscular blocking agent–associated anaphylaxis

BackgroundNeuromuscular blocking agents (NMBAs) are one of the most common causes of perioperative anaphylaxis. Although skin test positivity may help identify reactive NMBAs, it is unclear whether skin test negativity can guarantee the safety of systemically administered NMBAs. ObjectiveThis study aimed to evaluate the real-world safety of alternative NMBAs screened using skin tests in patients with suspected NMBA-induced anaphylaxis. MethodsA retrospective cohort of suspected NMBA-induced anaphylaxis were recruited among patients at Seoul National University Hospital from June 2009 to May 2021, and their characteristics and outcomes were assessed. ResultsA total of 47 cases (0.017%) of suspected anaphylaxis occurred in 282,707 patients who received NMBAs. Cardiovascular manifestations were observed in 95.7%, whereas cutaneous findings were observed in 59.6%. Whereas 83% had a history of undergoing general anesthesia, 17% had no history of NMBA use. In skin tests, the overall positivity to any NMBA was 94.6% (81.1% to culprit NMBAs) and the cross-reactivity was 75.7%, which is related to the chemical structural similarity among NMBAs; the cross-reactivity and chemical structure similarity of rocuronium were 85.3% and 0.814, respectively, with vecuronium; this is in contrast to 50% and 0.015 with cisatracurium and 12.5% and 0.208 with succinylcholine. There were 15 patients who underwent subsequent surgery with a skin test-negative NMBA; whereas 80.0% (12/15) safely completed surgery, 20.0% (3/15) experienced hypotension. ConclusionSimilarities in chemical structure may contribute to the cross-reactivity of NMBAs in skin tests. Despite the high negative predictability of skin tests for suspected NMBA-induced anaphylaxis, the potential risk of recurrent anaphylaxis has not been eliminated.

Pholcodine exposure increases the risk of perioperative anaphylaxis to neuromuscular blocking agents: the ALPHO case-control study

BackgroundNeuromuscular blocking agents (NMBAs) are among the leading cause of perioperative anaphylaxis, and most of these reactions are IgE mediated. Allergic sensitisation induced by environmental exposure to other quaternary ammonium-containing compounds, such as pholcodine, has been suggested. The aim of this study was to assess the relationship between pholcodine exposure and NMBA-related anaphylaxis. MethodsALPHO was a multicentre case-control study, comparing pholcodine exposure within a year before anaesthesia between patients with NMBA-related perioperative anaphylaxis (cases) and control patients with uneventful anaesthesia in France. Each case was matched to two controls by age, sex, type of NMBA, geographic area, and season. Pholcodine exposure was assessed by a self-administered questionnaire and pharmaceutical history retrieved from pharmacy records. The diagnostic values of anti-pholcodine and anti-quaternary ammonium specific IgE (sIgE) were also evaluated. ResultsOverall, 167 cases were matched with 334 controls. NMBA-related anaphylaxis was significantly associated with pholcodine consumption (odds ratio 4.2; 95% confidence interval 2.3–7.0) and occupational exposure to quaternary ammonium compounds (odds ratio 6.1; 95% confidence interval 2.7–13.6), suggesting that apart from pholcodine, other environmental factors can also lead to sensitisation to NMBAs. Pholcodine and quaternary ammonium sIgEs had a high negative predictive value (99.9%) but a very low positive predictive value (<3%) for identifying NMBA-related reactions. ConclusionsPatients exposed to pholcodine 12 months before NMBA exposure have a significantly higher risk of an NMBA-related anaphylaxis. The low positive predictive values of pholcodine and quaternary ammonium sIgEs precludes their use to identify a population with a high risk of NMBA-related anaphylaxis. Clinical trial registrationNCT02250729.

BACITRACIN ANAPHYLAXIS WITH MUCOSAL BUT NOT CUTANEOUS EXPOSURE

<h3>Introduction</h3> Evaluation of anaphylaxis involves obtaining a detailed history of medications and potential patient exposures, as well as documenting medications a patient currently tolerates. The route of administration of specific medications can sometimes be overlooked. <h3>Case Description</h3> A 58 year-old woman experienced an acute anaphylactic reaction consisting of cough, dyspnea, abdominal pain, and hypotension with systolic BP in the 80's, occurring 30 minutes after an outpatient surgery for scalp cyst removal. Peri-event tryptase was 30 ug/L and baseline tryptase was 6 ug/L. She had negative skin testing to latex and all local anesthetics used during the procedure. She subsequently had two additional episodes of anaphylaxis at home requiring self-administration of epinephrine and ER evaluation, but no clear inciting cause was identified. She was diagnosed with idiopathic anaphylaxis and started on H1 and H2 blockers, Montelukast, and Doxepin with no recurrence of symptoms. Further history revealed topical Neomycin/polymyxin B/Bacitracin ointment was applied to the scalp wound after cyst removal, and self-applied to the rectal mucosa due to diarrhea with both later episodes. She tolerated applying the ointment to intact skin. Skin testing was positive to bacitracin zinc and Polysporin (bacitracin + polymyxin); testing to neomycin and to polymyxin B sulfate alone were negative. <h3>Discussion</h3> Testing to bacitracin is indicated in peri operative anaphylaxis evaluation. In this case, anaphylactic reactions occurred when this was applied to incision wounds and mucosal surfaces which presumably increase systemic absorption. Bacitracin should be ruled out as a cause of peri operative anaphylaxis even with tolerance of topical bacitracin.

A CASE OF ANAPHYLAXIS TO SUGAMMADEX SKIN PRICK TESTING

<h3>Introduction</h3> Sugammadex is a modified gamma-cyclodextrin gaining increasingly common usage as an anesthetic medication for the rapid reversal of the neuromuscular blocking agents rocuronium and vecuronium. While considered safer than traditional reversal agents, sugammadex is becoming more widely recognized as a rare cause of peri-operative anaphylaxis. There are no standardized skin prick testing protocols or commercially available IgE assays for sugammadex, although previous literature has used an undiluted concentration of 100mg/ml for epicutaneous skin testing. <h3>Case Description</h3> A 57 year old woman with a medical history of anaphylaxis to bee sting experienced peri-operative anaphylaxis upon first time exposure to sugammadex. Despite adequate treatment, she had subsequent rebound anaphylaxis. Four months after her reaction she completed skin prick testing to sugammadex. During the first round of epicutaneous skin prick testing with a diluted concentration of 0.1mg/mL of sugammadex she experienced diffuse hives, throat closer, and hoarseness of voice requiring treatment with epinephrine, diphenhydramine, and steroids. She again had rebound of symptoms shortly thereafter, requiring transfer to the emergency department for monitoring. <h3>Discussion</h3> The evaluation of a patient with peri-operative anaphylaxis can be challenging. As the use of sugammadex increases, clinicians should be aware of its ability to cause anaphylaxis. This case demonstrates anaphylaxis in a sugammadex naive patient, both intra-operatively and then during in-office skin prick testing. The case raises awareness of the possibility for anaphylaxis at a concentration of 0.1mg/ml for epicutaneous skin testing and highlights the need for standardized skin prick testing protocols.

Clinical characteristics and allergen detection of perioperative anaphylaxis: a 12-year retrospective analysis from an anesthesia clinic in China

BackgroundAnaphylaxis during anesthesia is a rare but often a potentially life-threatening event for patients. Identifying culprit agents responsible for anaphylaxis is of great important for avoiding potential re-exposure to allergens, but it poses great challenge for anesthetists. This retrospective study aimed to analyze the culprits of patients with a history of perioperative anaphylaxis referred to an anesthesia allergy clinic in China, and to evaluate the role of allergy diagnostic tests in clinical practice.MethodsA total of 145 patients (102 female/43 male) who attended the Anesthesia Allergy Clinic for allergen detection between 1 January 2009 and 31 December 2020 were reviewed retrospectively. Clinical characteristics, results of allergy diagnostic tests including skin, and/or basophil activation tests, and the incidence of repeat anaphylaxis after use of recommended alternative anesthetics were obtained.ResultsOf these 145 patients, 109 patients (75.2%, 74 females/35 males) were determined to experience perioperative anaphylaxis. The most common presenting clinical feature was cardiovascular manifestations (n = 63, 57.8%). According to diagnostic work up, the most common causative agents for perioperative anaphylaxis were neuromuscular blocking agents (n = 35, 32.1%). After diagnostic work up, 52 patients underwent repeat anesthesia. None of these patients experienced recurrent anaphylaxis.ConclusionsThis study suggests that neuromuscular blocking agents are the main cause of perioperative anaphylaxis. For patients with perioperative anaphylaxis, allergy diagnostic tests are essential to identify causative agents, and to find suitable alternative drugs for the future planning of subsequent anesthetics.

Evolution of the medical devices for the protection of healthcare workers. Prevention of hemocontact infections in patients with an uncertain status

Background. Personal protective equipment (PPE) is an item of clothing designed to protect healthcare workers (HCW) or others from infection. PPE includes gloves, masks, gowns, respirators, goggles, face shields, headgear, boot covers, rubber shoes, and more.&#x0D; Objective. To describe the evolution of medical devices for HCW protection.&#x0D; Materials and methods. Review of literature data on this issue.&#x0D; Results and discussion. Medical gloves are divided into sterile and non-sterile. The purpose of wearing non-sterile gloves is to prevent contamination of the hands of HCW with microorganisms. They should be worn when there is a risk of contact with blood or other body fluids, patient secretions, or contaminated equipment. Gloves do not protect against contamination and after their use it is still necessary to treat hands with antiseptic. Latex gloves have good elasticity and flexibility, are convenient and anatomically suitable for hands, have a good sensitivity to touch. However, they can cause allergies or skin irritation. Latex allergy is the most common cause of perioperative anaphylaxis in children. It is recommended to use powder-free gloves. Nitrile gloves for examination manufactured by “Yuria-Pharm” are characterized by high toughness, elongated cuff, and special texture facilitating holding the instruments. Surgical masks consist of three layers of thermoplastic polymer located between the layers of nonwoven fabric. They are designed to protect against pathogens (mainly bacteria) transmitted in large droplets (&gt;5 μm). The Cochrane review did not show any convincing effect of wearing of surgical masks on reducing the risk of infectious complications during sterile surgical procedures. WHO recommends wearing surgical masks to prevent the transmission of coronavirus disease (COVID-19). N95 or FFP3 class respirators are recommended for aerosol-generating procedures (tracheal intubation, bronchoscopy) and for dangerous infections. N95 respirators are the standard for working with patients with COVID-19 in USA. They can be with a valve or without it. These respirators consist of thermoplastic polymer and nonwoven fabric and filter 95 % of particles sized ≥0.3 μm. They should tightly fit to the face and be tested for leaks before the contact with patient. A similar tactic should be used when wearing FFP3 respirator. Valve respirators are easier to use because the presence of a valve facilitates exhalation. The valve also increases comfort and prevents excessive accumulation of moisture under the respirator. Such respirators do not filter the exhaled air, so they do not protect others from infection. Another field of PPE application is its usage in hematocontact infections caused by hepatitis B/C virus and human immunodeficiency virus. The risk of HCW infection is associated with pricks, cuts, contact with the patient’s body fluids, and any invasive diagnostic or treatment procedures. The risk of patient’s infection is present in case of the improper instruments sterilization, use of non-sterile infusion solutions, transfusion of blood and its components, transplantation, and contact with biological fluids of the infected HCW. To reduce the risk of HCW infection, always wear gloves if there is a risk of contact with blood or other body fluids; never put the cap on the needle after using it; always keep a container for sharp objects on hand; carry out the necessary vaccinations; use PPE and safety needles, scalpels and syringes.&#x0D; Conclusions. 1. Wearing masks reduces the risk of COVID-19 transmission. 2. During aerosol-generating procedures it is necessary to use all available PPE. 3. When wearing a respirator, it is advisable to check its tightness. 4. The number of extra injections should be minimized.

Mast cell activation test in chlorhexidine allergy: a proof of concept

BackgroundImmediate drug hypersensitivity reactions are an increasing public health issue and a frequent cause of life-threatening anaphylaxis. Conventional confirmatory testing include skin tests and, for a few drugs, quantification of drug-specific immunoglobulin E (IgE) antibodies. However, none of these tests are absolutely predictive for the clinical outcome, and can yield false-negative and false-positive results. We performed a proof-of-concept study to assess whether a mast cell activation test could improve diagnosis of IgE-mediated chlorhexidine hypersensitivity, a common cause of perioperative anaphylaxis. MethodsHuman mast cells were generated from CD34+ progenitor cells and sensitised with patients' sera to become IgE+ human mast cells (dMCIgE+), and then incubated with chlorhexidine to assess degranulation. We compared the diagnostic performance of this mast cell activation test with serum from patients with and without positive skin test and basophil activation test to chlorhexidine. ResultsIn dMC sensitised with sera from patients with a positive skin test and basophil activation test to chlorhexidine showed drug-specific and concentration-dependent degranulation upon stimulation with chlorhexidine, determined by surface upregulation of the degranulation marker CD63. In contrast, dMC sensitised with sera from patients with a negative skin test and basophil activation test to chlorhexidine were unresponsive in the mast cell activation test. ConclusionsOur study suggests that the mast cell activation test can be used to diagnose IgE/FcεRI-dependent immediate drug hypersensitivity reactions. It also shows potential to assess the clinical relevance of drug-specific IgE antibodies in their ability to elicit mast cell degranulation, and therefore discriminate between allergy and sensitisation. Extended studies are required to verify whether this technique can be used in other causes of perioperative anaphylaxis.

Multiple drug allergies: Recommendations for perioperative management.

Life-threatening hypersensitivity reactions are more likely to occur in patients with a history of allergy, atopy, or asthma. Hence, in a patient who presented with a history of multiple drug allergies (MDA), an allergological assessment should be performed prior to surgical procedure. Drug allergies, being one of the causes of catastrophic events occurring in the perioperative period, are of major concern to anesthesiologists. Neuromuscular blocking agents are regularly used during anesthesia and are one of the most common causes of perioperative anaphylaxis. They are estimated to be responsible for 50%-70% of perioperative hypersensitivity reactions. Antibiotics and latex represent the next two groups of drug allergy. Allergic reactions to propofol are rare with an incidence of 1:60,000 exposures. Although intraoperative drug anaphylaxis is rare, it contributes to 4.3% of deaths occurring during general anesthesia. These recommendations discuss pathophysiology of MDA, preoperative evaluation, and anesthesia considerations as well as the prevention and management of allergic reactions in anesthetized patients with a history of MDA.

Identification and Management of Perioperative Anaphylaxis

The authors present a case of a patient with multiple episodes of perioperative anaphylaxis. The incidence and the most common causes of perioperative anaphylaxis are reviewed. The most common causes can vary by country and the type of perioperative medications used. The unique environment and the multiple medications and substances used in the anesthesia and surgical setting that make a definitive diagnosis challenging are outlined. A systematic strategy to recognize the reaction, identify the culprit, and direct future management are demonstrated. Management of the patient experiencing perioperative anaphylaxis requires close collaboration between the anesthesia, surgical, and allergy teams.

Peri-Operative Anaphylaxis-An Investigational Challenge.

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.

Integrating basophil activation tests into evaluation of perioperative anaphylaxis to neuromuscular blocking agents

BackgroundNeuromuscular blocking agents (NMBAs) remain the leading cause of perioperative anaphylaxis in Australia. Standard evaluation comprises history, skin tests, and in vitro specific immunoglobulin E tests. Drug provocation tests to suspected NMBA culprits are associated with a significant risk. Basophil activation testing (BAT) is a potentially useful in vitro test that is not commercially available in Australia or as part of standard evaluation. MethodsAll patients attending the Anaesthetic Allergy Clinic in Sydney, Australia between May 2017 and July 2018 exposed to an NMBA before the onset of anaphylaxis during their anaesthetic qualified for the study. We recruited 120 patients sequentially who received standard evaluation plus BAT using CD63, CD203c, and CD300a as surface activation markers. ResultsBAT results were expressed as % upregulation above the negative control and stimulation index (mean fluorescence index of stimulated sample divided by the negative control). We calculated cut-offs of 4.45% and 1.44 for CD63, and 8.80% and 1.49 for CD203c, respectively. Sensitivity was 77% with specificity of 76%. A subgroup of 10 patients with NMBA anaphylaxis had no sensitisation on skin tests. BAT using CD63 and CD203c showed sensitisation in six of these 10, and adding CD300a identified sensitisation in nine patients. BAT was positive in seven of nine patients with anaphylaxis of unknown aetiology. ConclusionsBAT may be a useful supplement to the standard evaluation in diagnosing NMBA anaphylaxis in patients with suggestive histories, but no sensitisation on skin tests. Ongoing study of this specific group of patients is required to clarify its utility in clinical practice.

Hypersensitivity Reaction to Perioperative Drug Mistaken for Local Anesthetic Systemic Toxicity in a Patient under Brachial Plexus Block

Perioperative anaphylaxis, although rare, is a severe, life-threatening unexpected systemic hypersensitivity reaction. Simultaneous administration of various drugs during anesthesia, the difficulty of communicate with patients in sedation and anesthesia, and coverage of the patient with surgical drapes are considered to be factors that impede early recognition of anaphylactic reactions. It is very important to perform an intradermal skin test because antibiotics are the most common cause of perioperative anaphylaxis. We report a case of negative-intradermal skin test antibiotic anaphylaxis mistaken for local aesthetic systemic toxicity without increase of serum tryptase for confirmative diagnostic biomaker during surgery under brachial plexus block. It is not possible to exclude the danger of anaphylaxis completely, even if it is negative-intradermal skin test and normal tryptase level. Therefore, anesthesiologists should be closely monitored and treated early for antibiotics related hypersensitive reaction, like other medicines during anesthesia.

CHLORHEXIDINE: AN INCREASINGLY RECOGNIZED CAUSE OF PERI-OPERATIVE ANAPHYLAXIS

Introduction Chlorhexidine is an antiseptic and disinfectant that has been increasingly used in medical care such as central venous lines, urinary catheters, and surgical skin preparations. It is also used in over-the-counter products such as mouthwash and cosmetics. A Pubmed search from 1994-2013 showed 65 case reports of chlorhexidine anaphylaxis. True incidence is likely to be underestimated as it is often overlooked as a causative factor. Case Description A 63 yo male with PMH of recent prostate cancer diagnosis presented for radical prostatectomy. An hour into his procedure he developed sustained hypotension which responded well to multiple rounds of epinephrine. His peri-operative tryptase was 48 ng/ml. His initial skin testing to lidocaine, rocuronium, cis-atrocurium, and propofol were negative. During his second tier of testing, he was negative to ketamine and fentanyl. The decision had been made to add on chlorhexidine. He was positive with the skin prick test. A week later he successfully tolerated a repeat prostrate surgery using a chlorhexidine alternative. Discussion The reaction is thought to be slower than with other perioperative agents. The reaction tends to occur more frequently in men with a mean age presentation of 58. Its presentation is often very difficult to treat requiring large doses of epinephrine. Chlorhexidine has historically been underestimated as cause of peri-operative anaphylaxis. In part it is due to limited recognition of its increasing trigger of anaphylaxis but also due to the slower onset of reaction. Chlorhexidine should be considered more regularly in peri-operative anaphylaxis testing.

CEFAZOLIN HYPERSENSITIVITY: A CASE OF OPTIMIZED CLARIFICATION

Introduction Antibiotics are the most common cause of perioperative anaphylaxis in the United States. Patients who have perioperative anaphylaxis due to cefazolin are often labeled as penicillin allergic, however many are selectively allergic to cefazolin, leading to unnecessary avoidance of penicillin. Case Description A 69-year-old male who developed perioperative anaphylaxis in the setting of robotic nephroureterectomy. During the procedure he had received cefazolin, midazolam, rocuronium, propofol, fentanyl, and lidocaine. Perioperatively he was noted to have urticarial lesions over his entire body as well as significant angioedema of the face. Tryptase drawn at that time was 15 ng/mL (normal Discussion This case builds upon the limited evidence that selective IgE- mediated hypersensitivity to cefazolin is responsible for immediate severe allergic reactions in the perioperative period and that patients in this scenario can often tolerate other beta-lactams antibiotics. This pattern is likely explained by the selectivity of the R1 side chain of cefazolin. A complete evaluation including skin testing to a panel including penicillin is essential to ensure accurate diagnosis and to avoid unnecessary avoidance of penicillins.

Perioperative anaphylaxis — Time for a NAP… 6!

Perioperative anaphylaxis — Time for a <scp>NAP</scp>… 6!

Required cefazolin concentration to maximize diagnostic accuracy of the basophil activation test for cefazolin-induced anaphylaxis.

Identifying the causative agent of perioperative anaphylaxis is key to preventing its recurrence. Besides skin testing, the basophil activation test (BAT) is increasingly being accepted as an additional and reliable method. Cefazolin seems to be a major cause of perioperative anaphylaxis. However, few studies have described use of the BAT for cefazolin-induced anaphylaxis. In this study, we aimed to determine the optimum cefazolin concentration required in the BAT for an accurate diagnosis. Seven patients who presented with immediate hypersensitivity to cefazolin and 21 control subjects were studied. We conducted skin tests and performed BATs using both CD203c and CD63 as markers of activated basophils. We measured the ratio of activated basophils after stimulation with serial dilutions of cefazolin and investigated the cefazolin concentration that resulted in better sensitivity and specificity. All patients demonstrated positive reactions to cefazolin, while all control subjects showed negative reactions on skin tests. The net percentage of both CD203c- and CD63-labeled activated basophils was greater when higher concentrations of cefazolin than previously reported were used. In control subjects, however, the number of activated basophils by cefazolin stimulation was negligible regardless of its concentration. In the case of CD203c, the sensitivity was 86% with a cefazolin concentration of 3mg/ml, while in the case of CD63, the sensitivity was 100% with a cefazolin concentration of 10mg/ml. Using a higher concentration of cefazolin than previously reported for the BAT might increase the accuracy of diagnosis of cefazolin-induced anaphylaxis.

Latex sensitization and allergy in Hospital General de Mexico surgery residents

The prevalence of latex allergy ranges from 0.8 to 6.5% and is the second cause of perioperative anaphylaxis. The main risk factors are being a health worker or latex producer, hours of latex gloves or products usage, exposure to other hand irritants, history of atopy, neural tube closure defects or numerous surgeries at early age. To determine the frequency of latex sensitization in resident physicians of the Hospital General de México surgical area. Prospective, cross-sectional, descriptive study where skin prick tests were applied to residents of the surgical area of the Hospital General de México, which depends on the Ministry of Health and is located in Mexico City. Ninety-two subjects were included and had skin tests practiced, with 11 surgical specialties participating. Latex sensitization in this population was 11.9%, whereas the presence of latex allergy was 10.8%. A high frequency of latex sensitization and allergy was demonstrated in Hospital General de Mexico surgery residents, which indicates the need for policies and procedures to be developed for health workers with latex allergy, as well as continuous training of employees on latex allergy.

Intradermal skin tests for rocuronium and cisatracurium in patients with a history of allergy: a retrospective study.

BackgroundNeuromuscular blocking agents (NMBAs) are a leading cause of perioperative anaphylaxis. However, the performance of systematic screening skin tests to detect reactions for NMBAs prior to general anesthesia is not recommended. We retrospectively examined intradermal tests (IDTs) for rocuronium and cisatracurium in patients with a history of allergy.MethodsWe reviewed the records of patients who underwent IDTs for NMBAs between January 1 and December 31, 2016. We analyzed the patients’ allergy histories and skin test results for NMBAs.ResultsThe overall prevalence of positive IDTs was 5.8% (26/451), and there was no significant difference in prevalence among allergy types (P = 0.655). In logistic regression analysis, there was no allergy history that had a significant effect on positive IDT for NMBAs.ConclusionsWe found no association between allergy history and positive skin test for NMBAs. Therefore, a systematic screening test for NMBAs or other anesthetic agents before anesthesia is not considered necessary even in patients with an allergy history.