3. prevalence
Difficult to determine incidence and prevalence
1 in 3500 to 1 in 13000 in french study
IgE and non IgE mediated reaction
Mortality 3-6 %
Multiple drug during anesthesia
no available diagnostic test that absolute accuracy
NMBA usually result skin test +ve for long time
9. history
1. Extent of sign of anaphylaxis
2. Drugs and related compounds
3. Time elapsed between administration and
onset of symptom
4. Previous allergies from drugs or related
compound
5. Underlying conditions
10. 1.Extent of sign of
anaphylaxis
In most cases
perioperative anaphylaxis is
characterized by severe respiratory
and cardiovascular manifestration !
11.
12.
13.
14. 2.Drugs and related
compounds
The most common is NMBAs
Others are latex, antibiotics
15.
16. 3.Time elapsed between administration
and onset of symptom
Clinical sign usually start within 5-10 min after IV
administration but may occur in second
NRL and antiseptics exhibit more delay onset and
generally occur in maintenance anesthesia or
recovery room
Colloid may immediated reaction or delay onset
17. 4.Previous allergies from drugs
or related compounds
Careful retrospecive assessment of medical
history and record
Identify risk of patients during preanesthetic
visit
19. tryptase
Neural serine proteinase
Mature β-tryptase reflect mast cell activation
Pro β-tryptase reflect mast cell number
Mast cell or basophil
60-120 min collection after event
Compare 2 sample in the same person
Persistent elevate in…..
False –ve & false +ve
23. NMBAs
All NMBAs can elicit anaphylaxis
Short acting depolarizing is greatest risk
succinylcholine !
Induce 2 type of reactions
- IgE dependent => NH4+ main antigenic epitope
- direct mast cell activation => benzylisoquinolinium
( cisatracurium is lowest risk of mast cell activate)
29. Data controversy in rocuronium
Cross reactivity between NMBAs is 65% by skin test
and 80% by RIA
Pattern of cross reactivity vary between person
Cross reactivity depend on configuration,
flexibility,inter-ammonium distant
Unusual to allergic to all NMBAs
But keep in mind some pt. might suffer from multiple
allergies
Subsequent anesthesia
32. Skin test
Undiluted drug except
succinylcholine,atracurium,mivacurium
0.03-0.05 cc for IDT
+ve IDT => 8 mm wheal or double in size
SPT or IDT
rocuronium and cisatracurium can elicit non
specific IDT +ve in non allergic pt.
33.
34.
35. no currently available NMBAs for in vitro
except suxamethonium (low sensitivity)
May use choline chloride,PAPC,morphine –
base solid phase sIgE
Histamine release test
BAT sen 60% spec 90%
36. Avoid NMBAs for such patient in future
anesthesia whenever possible!
38. Side effect usually from vasovagal or
anxiety reaction
Usually add epinephrine
Anaphylaxis is very rare
Amide-rare , ester< 1% for anaphylaxis
Ester metabolite=> PABA usually cause
type I reaction
Preservative => methylparaben,paraben
42. Hypotics
Cross reactivity between thiopental sodium
barbitone,methohexital( rare anaphylaxis)
Propofol => alkyl phenol that bear 2 isopropyl
groups that act as antigenic epitopes
- cross react with eggs ,soy and lechitins in
propofol vehicle ?
upto now no evidence support this postulate
43.
44. opioids
generalized reaction to opioids usually result
from nonspecific mast cell activation
Skin mast cell are sensitive to nonspecific
activation , in contrast to heart,GI,lung
How about basophil?
Classification of opioid
- phenanthrene (morphine,codeine)
- phenylpiperedine(phentanyl,meperidine)
- diphenylheptane(methadone,propoxyphene)
45. Most of reaction are not life-treatening reaction
Fentanyl appear not to activate mast cell
Data in cross reactivity of opioid subclass is
inconclusive
SPT for opioids is not useful
Placebo controlled chalenges may be required to
diagnose opioid allergy
46. NRL
Devide into 2 group
- atopic
- significant exposure=>HCP, Neural tube
defect
20% of perioperative anaphylaxis
Use questionaire
Rx => avoidance
47.
48.
49.
50.
51.
52.
53. Plasma volume expanders
4% of perioperative anaphylaxis
20% severe reaction
20 min after administration
Gelatin allergy
- Skin test (phadiac74) , BAT
HES
- skin test
54. Drextran => DIAR
- IgG immune complex dis
- prevent by hapten dextran (1Kd) infusion
- skin test is not established
Albumin anaphylaxis is anectodal case
55. Chlorhexidine and other antiseptics
Cationic biguanide
Chlorhexidine salt can trigger irritant
dermatitis
SPT 10 fold dilution of chlorhexidine
digluconate in 70% alcohol
sIgE (c8,Phadia)
Povidone iodine => anaphylaxis is rare
61. protamine
Isolate from the sperm of fish
Antidote for heparin
Significant histamine release
Previous exposure (NPH),heparin
neutralization, vasectomy,fish allergy may
risk for anaphylaxis
But these finding not confirm
Skin test ,sIgE may be helpful
62.
63. Increased risk of severe protamine reactions in NPH
insulin-dependent diabetics undergoing cardiac
catheterization
886 cases in 20 mths 651 cases received protamine
Received NPH 15/651
Major reaction 4/15 in NPH group
Major reaction 3/636 in non NPH group
Significant different in rate of reaction!
Circulation 1984 ;vol 70 : 788-792
64.
65. conclusion
Prevance of peri-operative anaphylaxis
Diagnostic approach
NMBAs is MCM cause
Diagnostic test
Anaphylaxis and anaphylactoid
Almost procedure and medication can cause
peri-operative anaphylaxis