Subsequent Anesthesia Research Articles

Neuromuscular blocking agent drug challenge: a literature review and protocol proposal with biological evaluation.

Drug challenge is the gold standard for identifying causative agents of drug allergies. Although clinical guidelines have recently been published, they do not recommend neuromuscular blocking agent (NMBA) drug challenges. NMBA challenges are rendered difficult by the lack of homogeneity of routine allergy work-ups and the necessity of a specialised setting. Several scenarios support NMBA challenges, such as an ambiguous allergy work-up, a high suspicion of a false-positive skin test or identification of a well tolerated alternative NMBA strategy. Furthermore, routine allergy work-ups may not recognise non-IgE mechanisms, such as IgG or MRGPRX2, whereas drug challenges may reveal them. Finally, if the culprit NMBA is not identified, subsequent anaesthesia regimens will be challenging to implement, resulting in increased risk. This literature review discusses the indications, strategies, doses, monitoring methods, limitations, and unresolved issues related to drug challenges for NMBAs. The literature review included randomised controlled trials, observational studies, reviews, case reports, series, and comments on humans. Studies were retrieved from databases (PubMed) and electronic libraries (OVID, EMBASE, Scopus, etc.). All studies that referred to the NMBA challenge were included without publication date limitations. NMBA challenge may be considered in NMBA anaphylaxis patients with inconclusive or ambivalent IgE diagnostic work-up under controlled conditions (presence of anaesthetists and allergists with continuous monitoring in a secured environment). To illustrate its utility, a case report of a double NMBA challenge in a patient with NMBA cross-reactivity is presented, along with biological explorations to detect subclinical cellular activation, a novel aspect of this procedure. Drug challenges could be implemented during the NMBA allergy work-up under strict safety conditions at specialised centres with close collaboration between anaesthetists and allergists. This could decrease uncertainty and contribute to defining a safer strategy for subsequent anaesthetic drug regimens.

Short-Term Preexposure to Novel Enriched Environment Augments Hippocampal Ripples in Urethane-Anesthetized Mice.

Learning and memory are affected by novel enriched environment, a condition where animals play and interact with a variety of toys and conspecifics. Exposure of animals to the novel enriched environments improves memory by altering neural plasticity during natural sleep, a process called memory consolidation. The hippocampus, a pivotal brain region for learning and memory, generates high-frequency oscillations called ripples during sleep, which is required for memory consolidation. Naturally occurring sleep shares characteristics in common with general anesthesia in terms of extracellular oscillations, guaranteeing anesthetized animals suitable to examine neural activity in a sleep-like state. However, it is poorly understood whether the preexposure of animals to the novel enriched environment modulates neural activity in the hippocampus under subsequent anesthesia. To ask this question, we allowed mice to freely explore the novel enriched environment or their standard environment, anesthetized them, and recorded local field potentials in the hippocampal CA1 area. We then compared the characteristics of hippocampal ripples between the two groups and found that the amplitude of ripples and the number of successive ripples were larger in the novel enriched environment group than in the standard environment group, suggesting that the afferent synaptic input from the CA3 area to the CA1 area was higher when the animals underwent the novel enriched environment. These results underscore the importance of prior experience that surpasses subsequent physical states from the neurophysiological point of view.

Perioperative immediate hypersensitivity incidence, clinical characteristics, and outcomes after allergological evaluation: A multi-disciplinary protocol from tertiary hospital, Thailand.

Perioperative immediate hypersensitivity reaction (POH) is an immediate hypersensitivity reaction during an anesthesiologist monitored procedure. We report data of clinically-suspected POH (csPOH) patients undergoing an allergist-performed unified diagnostic workup algorithm for POH. To describe the characteristics of patients with csPOH, POH events, and the POH outcomes of procedures after the unified diagnostic workup algorithm for POH. A prospective cohort was conducted in adult patients with csPOH at Siriraj Hospital, a tertiary hospital, in Thailand from January 2018 to August 2022. Diagnostic workup for POH by the allergist included an initial assessment, followed by comprehensive allergological evaluation. Patients were then follow-up for POH outcomes during subsequent anesthesia procedures. Of 68 patients were csPOH, only 52 patients were diagnosed with POH by allergists. The incidence was 1:4,304 anesthetic procedures for POH, and 1:11,900 anesthetic procedures for at least grade III POH. Most patients had a grade III (51.2%) or II (46.4%) reaction. The leading identified causative agents were antibiotics (36.8%), antiseptics (21%), latex (13.1%), and morphine (13.1%). Cefazolin and chlorhexidine were the most common antibiotic and antiseptic, respectively. During a median follow-up time of 2.1 years, all 14 patients completing comprehensive allergological evaluation underwent subsequent anesthesia without recurrence of POH. The incidence of POH at our hospital was comparable to the global incidence. Antibiotics were the most common causative agent. Complete records, collaboration among the multidisciplinary team, and comprehensive evaluation of POH allow for safe subsequent procedures.

Оптимізація анестезіологічного забезпечення пері- та післяопераційного періоду при хірургічному лікуванні колоректального раку

Мета дослідження — вибір оптимального методу анестезіологічного захисту хворих від операційної агресії при хірургічному лікуванні колоректального раку. Проведено порівняльний аналіз клінічних показників і результатів лікування при використанні атаралгезії з подальшою аналгезією наркотичними анальгетиками та комбінованої методики з використанням низькопотокової анестезії севофлураном та епідуральної аналгезії з подальшим подовженим епідуральним знеболюванням. Показано вірогідну перевагу комбінованої методики перед тотальною внутрішньовенною анестезією за рахунок нормодинамічного типу гемодинаміки упродовж всієї операції, ранньої регресії постнаркозної депресії і можливості екстубації пацієнта в операційній, ефективної аналгезії в ранньому післяопераційному періоді. Методика подовженої епідуральної аналгезії порівняно з опіатною аналгезією забезпечила значне зниження потреби в опіоїдних анальгетиках, ефективну і якісну аналгезію в післяопераційному періоді, нівелювала побічні ефекти опіатних препаратів, знизила тривалість перебування пацієнта у відділенні інтенсивної терапії. Впроваджена методика дозволила знизити частоту післяопераційної летальності, кількість ускладнень, середню тривалість ліжко-дня і частоту повернень пацієнтів у відділення інтенсивної терапії.

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.

The Narrow Band Imaging as an essential complement to White Light Endoscopy in Recurrent Respiratory Papillomatosis diagnostics and follow-up process.

The aim of the study is to discuss the role of NBI imaging in upper respiratory papillomatosis (RRP). In the available literature on the subject, as of 2009, there have been 117 publications on NBI imaging focusing on the diagnosis of the upper respiratory and digestive tract, especially the larynx. They discuss the following diagnostic and therapeutic problems: identifying an abnormal vascular pattern within the mucosa, differentiating benign and malignant lesions, assessing the nature of lesions under the leukoplakia plaque, pre-operative definition of laryngeal cancer margins, supporting laser procedures to obtain safe margins, postoperative monitoring after cancer treatment, detecting second simultaneous and metachronic neoplasms and primary tumors in the case of metastases from an unknown primary site. Few reports have been devoted to the assessment of the extent and recurrence of RRP. Due to its recurrent nature, this pathology deserves special attention as it requires multiple inspections and manipulation within the larynx. It also applies to the pediatric population, where there should be no margin for underestimating or overestimating changes, because any suspicion of recurrence results in subsequent general anesthesia. Hence the attempt to define an unambiguous picture of RRP recurrence and the criteria for referring for subsequent surgical treatment.

Perioperative hypersensitivity reactions during childhood and outcomes of subsequent anesthesia.

Pediatric perioperative hypersensitivity reactions are rare, and possibly life-threatening. Identification of precise etiology is crucial to circumvent future re-exposures. We aim to evaluate the clinical features and triggers of perioperative hypersensitivity reactions in children, and determine the outcomes of subsequent general anesthesia. A retrospective study was performed with patients who underwent skin testing for general anesthesia between 2007 and 2019. We noted demographic features and skin tests (neuromuscular blocking agents, induction agents, and antibiotics). We also recorded specific immunoglobulin Es or provocation results of drugs or substances (latex, chlorhexidine, and ethylene oxide) that patients were exposed to antecedent to the reaction. Telephone interviews were performed to determine the current status of the participants and reconsider subsequent anesthesia. We enrolled 50 children (58% male) with a suspected perioperative hypersensitivity reaction. The median age was 6.67 (4.4-11.5) years, and the median time between the reaction, and skin tests was 4 (1-36) months. The most common potential causative agents were neuromuscular blocking agents (n=8), midazolam (n=3), ketamine (n=2), and propofol (n=1). Three children exhibited hypersensitivity to more than one general anesthetics, and three patients were allergic to latex. Thirty-one patients received subsequent anesthesia, and only one patient had a hypersensitivity reaction. A previous history multiple of general anesthesia administration (≥2) increased the risk of reaction to neuromuscular blocking agents. Data on perioperative hypersensitivity reactions during childhood are rare due to limited diagnostic procedures. Different preference of general anesthetics may change the causative agent. Meticulous evaluation is necessary to safely administer subsequent anesthesia.

Learning boosts the decoding of sound sequences in rat auditory cortex.

Continuous acoustic streams, such as speech signals, can be chunked into segments containing reoccurring patterns (e.g., words). Noninvasive recordings of neural activity in humans suggest that chunking is underpinned by low-frequency cortical entrainment to the segment presentation rate, and modulated by prior segment experience (e.g., words belonging to a familiar language). Interestingly, previous studies suggest that also primates and rodents may be able to chunk acoustic streams. Here, we test whether neural activity in the rat auditory cortex is modulated by previous segment experience. We recorded subdural responses using electrocorticography (ECoG) from the auditory cortex of 11 anesthetized rats. Prior to recording, four rats were trained to detect familiar triplets of acoustic stimuli (artificial syllables), three were passively exposed to the triplets, while another four rats had no training experience. While low-frequency neural activity peaks were observed at the syllable level, no triplet-rate peaks were observed. Notably, in trained rats (but not in passively exposed and naïve rats), familiar triplets could be decoded more accurately than unfamiliar triplets based on neural activity in the auditory cortex. These results suggest that rats process acoustic sequences, and that their cortical activity is modulated by the training experience even under subsequent anesthesia.

Perioperative Allergic Reactions: Allergy Assessment and Subsequent Anesthesia

Evidence-based guidelines are needed in the United States to improve evaluation of perioperative allergic reactions including recommendations for subsequent anesthesia. To identify causative agent(s) and evaluate patients' tolerability of subsequent anesthesia in patients evaluated by Allergy/Immunology (A/I) at Massachusetts General Hospital. We performed a retrospective review of patients referred to the outpatient A/I clinic for perioperative allergic reactions between October 2003 and May 2017. Patient demographics, atopic history, and prior adverse drug reactions were reviewed. Patients underwent a comprehensive evaluation with testing including skin testing (ST), drug challenges (when appropriate), tryptase level measurement, and specific IgE to latex measurement. Tolerance of subsequent procedures requiring anesthesia was assessed. Of 123 patients referred, 74 (60%) were female and the mean age was 46 (±18) years. At least 1 causative agent was identified in 28 patients (24%, n= 28 of 118). Seventeen of 28 (61%) patients were ST positive to an antibiotic, including 13 (46%) positive to cefazolin; 3 patients (11%) had a positive latex specific IgE. Of 85 patients who had subsequent anesthesia with a known outcome, 78 (91%) did not have another perioperative allergic reaction. Two of 5 patients with an elevated baseline tryptase level did not tolerate subsequent anesthesia. The majority of patients safely received subsequent anesthesia after comprehensive A/I evaluation for their perioperative allergic reactions; however, improved algorithmic care is needed in the United States. Among ST-positive patients (24%), antibiotics (especially cefazolin) were the most common culprits. An elevated baseline tryptase level was associated with an increased risk of recurrent perioperative allergic reactions.

Investigation of perioperative hypersensitivity reactions: an update.

The purpose of this review is to provide an update on how best to manage the investigation of suspected perioperative hypersensitivity reactions based on recent literature and key publications. In the past two years, several very important initiatives have been taken in the field of perioperative hypersensitivity. The 6th national audit project in the United Kingdom has provided new knowledge through a series of studies, including a nationwide prospective study, and the European Academy of Allergy and Clinical Immunology has commissioned a position paper with updated recommendations for investigations. Lastly, a large international working group comprising experts in anesthesiology, allergology, and immunology, the International Suspected Perioperative Allergic Reactions group, has published a series of articles providing updates and new insights into several different key areas of perioperative hypersensitivity. The investigation of perioperative hypersensitivity reactions is highly complex and aims to identify the correct culprit to ensure future avoidance but also to disprove allergy to other suspected culprits, making them available for subsequent anesthesia. To achieve this, close collaboration between anesthesiologists and allergists is called upon to ensure the best possible outcome for the patient.

Interpreting the results of early skin tests after perioperative anaphylaxis requires special attention: a case report and review of literature

Skin tests are the gold standard for detecting the culprit drug of anaphylaxis, and should ideally be performed after an interval of 4–6 weeks after the reaction to avoid false-negative results. However, when re-operation cannot be delayed and early allergy tests are necessary, special attention is required during subsequent anesthesia, because early skin tests tend to produce false-negative results. This report presents a case of rocuronium-induced anaphylaxis in which early skin tests showed negative results for all the drugs tested. The second anesthesia was safely performed by avoiding all the drugs used for the first anesthesia. Ultimately, skin tests and basophil activation tests (BATs) performed after re-operation demonstrated rocuronium as the drug responsible for anaphylaxis. We recommend performing BATs in addition to skin tests to improve the accuracy of diagnosis of anaphylaxis. In this report, we also discuss interpretation of the results of early skin tests and subsequent selection of drugs for anesthesia. After postponement of surgery due to anaphylaxis, we are often required to perform allergy tests at an early stage if re-operation cannot be delayed. In such cases, skin test results alone should not be used to guide subsequent anesthesia management to avoid recurrent anaphylaxis.

Impact of preanaesthetic echocardiography on the planned anaesthetic management of cats

ObjectiveTo assess the impact of preanaesthetic echocardiography on the subsequent intended anaesthetic management plan in cats with incidental clinical findings that may indicate cardiac disease. Study designClinical study involving cats undergoing echocardiography and subsequent anaesthesia. AnimalsA total of 40 client-owned cats. MethodsEchocardiography was performed in conscious cats and the information was used to plan anaesthesia or sedation. An information sheet including relevant history, temperament, body condition score, clinical examination findings, current medication and results of any relevant tests such as haematology, biochemistry or Doppler blood pressure measurement was sent to three specialist anaesthetists and virtual case management plans were designed for each cat in two steps: step 1) anaesthetists were unaware of echocardiography results; and step 2) anaesthetists were aware of echocardiography results. In the second step the anaesthetists documented any changes to their original management plan, as either ‘step-up’ or ‘step-down’. ResultsOf the 40 cats, 26 had murmurs, four had a gallop rhythm, four had both findings and six had other findings. Pathology of potential haemodynamic significance was found on echocardiography in 23 cats, 17 of which anaesthetists had correctly identified as having disease before echocardiography. A proportion of cats with murmurs were subsequently deemed to have no significant pathology after echocardiography. Echocardiography findings in these cases were: dynamic left ventricular outflow tract obstruction (DLVOTO) without hypertrophy; DLVOTO without hypertrophy + dynamic right ventricular outflow tract obstruction (DRVOTO); DRVOTO; valvular dysplasia; normal. In a median of 26/40 (range 16–38) of cases, the anaesthetic plan was changed after provision of further information; in 15/40 (8–20) cases, this was a ‘step-up’ in care and in eight/40 (6–23) it was a ‘step-down’ in care. In cases with atrial enlargement (left atrium to aortic ratio of >1.6) and deemed at risk of cardiac failure, alpha-2 agonist use changed considerably with availability of echocardiography findings. Conclusionand clinical relevance Where there are abnormal cardiac findings on clinical examination in cats, echocardiography is required to accurately assess anaesthetic risk . The availability of echocardiographic information positively influences anaesthetic management.

Rib Fracture in Buffalo with Ruminal Cannula

Background: Buffalos are very rustic animals that are adapted to adverse conditions, but the lack of adequate management can increase the susceptibility of these animals to several diseases. Rib fracture in this species is usually related to mineral deficiency and complications resulting from unappropriated management. Rib fractures in ruminants are rarely diagnosed and usually present conservative treatment; however, cases with presence of contaminated wounds require extra attention. The objective of this work was to report an atypical case of open fracture of the last rib in a buffalo with ruminal cannula, describing the case from diagnosis to surgical treatment.Case: An adult female water buffalo (Bubalus bubalis) that was well fed and receiving minerals, with implantation of a ruminal cannula, presented a lesion around the ruminal cannula, with increasing volume, exudation, and myiasis. Thegeneral parameters and behavior of the animal were apparently normal. The animal presented normal appetite and respiration and good physical condition and nutritional state, with pain reaction to the touch in the region of the lesion andtheir adjacencies; it presented no claudication and reluctance to remain in left lateral decubitus, and no discomfort. The clinical inspection of the cutaneous lesion showed an oblique-type fracture in the body of the last left rib, with exposed bone in the lumbar region and extremity exposed to the ruminal cannula, already presenting necrosis. The region was cleaned, removing larvae (myiasis) for better exposition of the fracture; in the following day, an osteotomy was done to remove exposed bone fragments. A trichotomy, cleaning, and debridement of the lesion and their adjacencies were done, with subsequent sedation and locoregional paralumbar anesthesia with lidocaine for resection of necrotic bone fragments. Cutaneous and muscle syntheses were not done because the region presented permanent contact with the rumen content. The post-operatory management was based on daily cleanings and bandages, with administration of antibiotics every 48 h for 20 days. The total recovery of the animal occurred within 45 days after the surgery.Discussion: Despite rib fractures in buffalos are mainly related to mineral deficiency, the case of the present study showed that these fractures are not always related to pre-existent causes. The clinical signs of the lesion were focal, because they refer to an open fracture that did not caused injuries to other structures, thus not determining an associated symptomatology. Opened rib fractures are rare, and most of them are healed by second intention without veterinary intervention. Regarding open fractures, the decontamination and debridement of a lesion and their adjacencies with removal of necrotic tissuesand use of antibiotics are essential for prevention of infections. When the lesion is in a contaminated region by permanent contact with rumen content, as in this case, daily cleaning with bandages is needed for a best healing, but synthesis oftissues is not indicated because there is a possibility of contamination and formation of abscesses. Therefore, procedures that ensure the decontamination of the wound and prevention of infections with prolonged use of antibiotics are essential for a better healing of open rib fractures in regions that are subjected to constant contamination.

Early Experience with Variant Two-Stage Approach in Surgical Management of Inflammatory Bowel Disease Colitis in the Pediatric Population.

Introduction: Multistaged surgical management of inflammatory bowel disease (IBD), culminating in ileal pouch-anal anastomosis (IPAA), can provide cure for refractory IBD symptoms while maintaining fecal continence. Surgical approaches to IPAA historically included a three-stage approach done by subtotal colectomy (STC) followed by IPAA with diversion. Recently, a variant two-stage approach without diversion at IPAA has become increasingly utilized, yet evidence of the efficacy of this approach is limited. Methods: Retrospective review of patients aged 5-21 years who underwent initial STC, followed by a total proctocolectomy with IPAA +/- diversion for medically refractory IBD from January 2010 to August 2018 (n = 25). Results: Majority of IPAA procedures were done laparoscopically (88.5%). Thirteen patients (52%) underwent two-stage variant IPAA. There were no differences in readmission rates (66.7% versus 53.8%, P = .5) or reoperation rates (50% versus 30.8%, P = .3) between groups. Forty percent of patients experienced a complication after IPAA. Complication rates were similar between two-stage and three-stage IPAA groups (38.5% versus 50%, P = .33). Complications within the two-stage group included anastomotic leak, pouchitis, wound infection, anastomotic stricture, and incarcerated hernia. Complications within the three-stage group included bloody ostomy output, dehydration, anastomotic stricture, small bowel obstruction, and pouch volvulus. Conclusions: Treatment of refractory IBD in children remains challenging, but STC followed by IPAA is an approach that provides symptom relief and preserves continence. Complication rates remained unchanged regardless of whether IPAA was conducted with or without diversion, demonstrating that the two-stage variant approach is a safe and feasible treatment that may reduce subsequent anesthesia exposure and trips to the operating room.

IPEG 2019 The 28th Annual Congress for Endosurgery in Children March 20-22, 2019, Santiago, Chile.

IPEG 2019 The 28th Annual Congress for Endosurgery in Children March 20-22, 2019, Santiago, Chile.

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.

Management of suspected immediate perioperative allergic reactions: an international overview and consensus recommendations

Suspected perioperative allergic reactions are rare but can be life-threatening. The diagnosis is difficult to make in the perioperative setting, but prompt recognition and correct treatment is necessary to ensure a good outcome. A group of 26 international experts in perioperative allergy (anaesthesiologists, allergists, and immunologists) contributed to a modified Delphi consensus process, which covered areas such as differential diagnosis, management during and after anaphylaxis, allergy investigations, and plans for a subsequent anaesthetic. They were asked to rank the appropriateness of statements related to the immediate management of suspected perioperative allergic reactions. Statements were selected to represent areas where there is a lack of consensus in existing guidelines, such as dosing of epinephrine and fluids, the management of impending cardiac arrest, and reactions refractory to standard treatment. The results of the modified Delphi consensus process have been included in the recommendations on the management of suspected perioperative allergic reactions. This paper provides anaesthetists with an overview of relevant knowledge on the immediate and postoperative management of suspected perioperative allergic reactions based on current literature and expert opinion. In addition, it provides practical advice and recommendations in areas where consensus has been lacking in existing guidelines.

Fentanyl-associated anaphylaxis in an infant with tetralogy of Fallot: a case report

BackgroundAnaphylactic reactions to opioids are rare. We report a case of an infant who experienced fentanyl-induced anaphylaxis.Case presentationA 2-month-old male was scheduled to undergo a Blalock-Taussig shunt. Following uneventful anesthetic induction, he experienced profound hypotension and generalized erythema. Anaphylaxis was clinically diagnosed, and he was treated with epinephrine, vasopressin, and fluids. The surgery was canceled, and he was transferred to the intensive care unit after restoration of his hemodynamic status. Intradermal testing was performed for all of the drugs given during the anaphylactic event on postoperative day (POD) 3. The results showed a positive reaction to fentanyl. For the second anesthesia scheduled on POD 5, morphine sulfate was selected as an alternative opioid. Anesthesia was maintained uneventfully with sevoflurane, morphine, and rocuronium.ConclusionIntradermal testing revealed fentanyl anaphylaxis. We were able to manage the patient by using of morphine as an alternative opioid for the subsequent anesthesia.

Assessing cross-reactivity to neuromuscular blocking agents by skin and basophil activation tests in patients with neuromuscular blocking agent anaphylaxis

BackgroundFollowing diagnosis of neuromuscular blocking agent (NMBA) anaphylaxis, identifying safe alternatives for subsequent anaesthesia is critical. A patient with anaphylaxis to one NMBA can also have an allergic reaction to other NMBAs (cross-reactivity). Whilst drug provocation testing is standard for identifying or excluding allergy, there is significant risk. In vitro, after an allergen activates basophils, basophils express surface activation markers that can be measured by basophil activation testing (BAT). We compared cross-reactivity between NMBAs assessed by BAT against that by skin testing. MethodsAll patients attending an anaesthetic allergy clinic in Sydney, Australia between May 2017 and July 2018 diagnosed with NMBA anaphylaxis qualified for this study comparing intradermal skin tests and BAT with a panel of NMBAs (rocuronium, vecuronium, pancuronium, suxamethonium, cisatracurium). ResultsOf the 61 patients participating, sensitisation on skin testing and on BAT completely matched in only nine patients (15%). Sensitisation was not in agreement for pancuronium, cisatracurium and rocuronium, but was in agreement for vecuronium and suxamethonium. Nine patients with negative skin tests subsequently tolerated cisatracurium, and one false positive on BAT to cisatracurium was detected. ConclusionsThe utility of BAT in identifying safe NMBAs for subsequent anaesthesia needs further evaluation. BAT detects a different cross-reactivity profile to skin tests. Negative skin testing and BAT might increase confidence in performing drug provocation testing, but this and follow-up of subsequent anaesthesia in our cohort is necessary to determine the clinical significance of BAT sensitisation.

Acute Management, Diagnosis, and Follow-Up of Suspected Perioperative Hypersensitivity Reactions in Flanders 2001-2018

Despite numerous efforts to describe the clinical manifestations and the epidemiology of perioperative hypersensitivity (POH), there remains room to increase awareness among anesthetists and immunologists/allergists. To report the findings of a 17-year survey of suspected POH in Antwerp, Belgium. We analyzed clinical and diagnostic data from 715 patients referred because of a suspected POH reaction, between January 1, 2001, and May 31, 2018. A total of 456 patients demonstrating a POH could be queried about subsequent anesthesia. A total of 608 cases formed the final dataset; 208 had a non-life-threatening reaction and 400 a life-threatening reaction. In life-threatening reactions, hypotension was predominating. In the non-life-threatening reactions, 83.9% of the patients displayed cutaneous manifestations. In life-threatening reactions, intravenous adrenaline and fluids were administered in 75.7% and 31%, respectively, and 41.3% had their intervention abandoned. Mast cell activation (MCA) was mainly, but not exclusively, observed in severe grades but did not predict the mechanistic process nor the culprit. A cause was identified in 77.8% of severe and 48.6% of milder cases. Main culprits were neuromuscular blocking agents, latex, cefazolin, and dyes. A total of 156 cases had uneventful anesthesia, except 1 patient who was inadvertently re-exposed to hidden chlorhexidine. This study highlights that there is room for an improved acute management and an optimized diagnostic workup that should not be restricted to patients with severe reactions and/or showing MCA.