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L ’anaphylaxie

L ’anaphylaxie. ( ou le contraire de la phylaxie). Ana 1. Charles Richet (1850-1935). Ana 2. Sea Anemone. Ana 3. De l ’action anaphylactique de certains venins (par MM Portier et Richet)

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L ’anaphylaxie

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  1. L ’anaphylaxie (ou le contraire de la phylaxie) Ana 1

  2. Charles Richet (1850-1935) Ana 2

  3. Sea Anemone Ana 3

  4. De l ’action anaphylactique de certains venins (par MM Portier et Richet) Nous appelons anaphylactique (contraire de la phylaxie) la propriété dont est doué un venin de diminuer au lieu de renforcer l ’immunité lorsqu’il est injecté à doses non mortelles. ... si, au lieu d ’injecter des chiens normaux, on injecte des chiens ayant reçu trois semaines auparavant une dose non mortelle (de venin de physalie), des doses de 0,08 à 0,25 ml deviennent très rapidement mortelles, ce qui démontre l ’effet anaphylactique de la première injection... Ana 4

  5. Anaphylaxie: degré de gravité • Symptômes cutanés et muqueux: prurit paume des mains et plante des pieds, érythème et urticaire généralisés, œdème palpébral et labial, injection conjonctivale, congestion nasale (éternuements !) • Manifestations cardiovasculaires , respiratoires et digestives modérées: dyspnée, tachycardie, hypotension, nausées,vomissements, diarrhées. • Etat de choc, bronchospasme sévère • Arrêt cardio-respiratoire Ana 5

  6. Signs/symptoms of anaphylaxis Urticaria, angioedema 239/266(90) Dyspnea,wheezing 159(60) Diarrhea, abdominal cramps, emesis 122(46) Dizziness, syncope 76(29) Flushed skin 74(28) Laryngeal oedema, dysphonia, dysphagia 64(24) Hypotension 52(19) Rhinitis, sneezing 44(16) Conjunctivitis,periorbital oedema 33(12) Substernal dyscomfort 15(6) Headache 14(5) Generalized pruritus without rash 12(4) Transient blindness, seizure 9(3) Ana 6 ana5b Kemp S., LockeyRF 1995

  7. The Mast cell Ewan pw 1998 (Ana 7)

  8. Preformed mast cell mediators • Vasoactive mediator: histamine • Chemotactic mediators: neutrophil and eosinophil chemotactic factor • Enzymes: neutral proteases ( tryptase, chymase), acid hydrolases (ß-glucuronidase, ß-hexosaminidase, arylsulfatase A ) • Proteoglycans: heparine, chondroitine sulfate (Ana 8)

  9. Rapidly formed, newly synthesizedmast cell mediators • Arachidonic acid metabolites • Cyclo-oxygenase pathway: PGD2, THRX A2 • Lipoxygenase pathway: LTB4, LTC4, LTD4, LTE4 • Platelet activating factor (PAF) • Cytokines:IL4, IL13, TNFα, GM-CSF • Adenosine • Free oxygen radicals (Ana 9)

  10. Mast cell mediators Williams CMM 2000 (Ana 10)

  11. IgE-mediated Complement activation Direct mediator release Unknown Venoms, enzymes,foods, airborne allergens, human proteins, heterologous serum, medicaments human proteins, dialysis hypertonic solutions, drugs, plasma expanders exercise (+food), cold, idiopathic Mechanisms and agents responsible of anaphylactic reactions Lichtenstein lm 1991 (Ana 11)

  12. Pulmonary vascular resistance (anesthetized allergic dogs) mmHg/l/min Mink sn 1998 (Ana 12)

  13. Respiratory mechanics(anesthetized allergic dogs) min B.Revenas, Acta Anesth.Scand 79 (Ana 13)

  14. Hemodynamics in anaphylactic shock (anesthetized allergic dogs) Mink sn 1998 (Ana 14)

  15. Leukotrienes and cardiac anaphylaxis(guinea pig heart) R.Levi, et al 82 (Ana 15)

  16. H1/H2r in the human heart %max r/l ventric r/l atria Coron.art. log[his] Ginsburg R 1983 Ana 16

  17. CV effects of histamine infusion Vigorito C 1983 Ana 17

  18. CV effects of histamine infusion Vigorito C. 83 (Ana 18)

  19. Sheikh a, Alves b 2000 (Ana 19)

  20. Patients with anaphylactic episodes from food Crustaceans26/88 Peanuts 20 Food additives or spices 15 Nuts (walnuts, brazil nuts…) 12 Beef, Pork 10 Eggs 3 Tuna 1 Banana 1 Kemp sf, Lockey rf 1995 (Ana 20)

  21. Patients with anaphylaxis from medication Nonsteroidal anti-inflammatory drugs 27/52 Aspirin 20 Penicillin, cephalosporin, macrolides 13 Insulin 7 Protamine 1 Salmon calcitonin 1 Methylprednisolone 1 Codeine, dextromethorphan 2 Kemp SF, Lockey RF 1995 (Ana 21) +++++----------

  22. Muscle relaxants (610) Hypnotics(61) Bezodiazepines(22) Morphinics(36) Plasma substitutes(51) suxamethonium 240 vecuronium 220 atracurium 88 pancuronium 29 thiopental 31 propofol 29 ethomidate 1 midazolam 7 flunitrazepam 9 diazepam 6 fentanyl 18 gelatine 40 dextrans 8 Anaesthetic drugs responsible foranaphylactic shock Guéant JL, Laxenaire MC 1995 Ana 22

  23. Hyperosmolar ~1500 mosm/ml Lower osmolar ~350-700 mosm/ml Iso-osmolar Ionic monomers: iothalamate,diatrizoat Nonionic monomers: iopamidol, metrizamide, ioversol Ionic dimers: ioxaglate Nonionic dimers: iodixanol Radiocontrast Media Stellato C, Adkinson NF 1998 Ana 23

  24. Cardiac Allergy-like Pain Nephrotoxicity HOCA 156/505 LOCA 42 HOCA 30 LOCA 2 HOCA 14 LOCA 1 HOCA 8 LOCA 10 Adverse reactions to radio-contrast media HOCA:meglumine/Na diatrizoate LOCA:iohexol Steinberg EP 1992 (Ana 24)

  25. Grade 1:minor allergicreactions involving skin only (eg urticaria) discontinue causativeagent keep patient supine; assess vital signs give oral anti-H1 observe 1 hour if good response: discharge on oral anti-H1 during 48 h; contact immunology dept Anaphylaxis: treatment (1) Gavalas M 1998 ( Ana 25)

  26. Grade 2:moderate severity ± skin manifestations ± abdominal cramps , nausea + dyspnea +/or BP drop>20 mmHg discontinue causative agent resuscitation room monitor vital signs high FIO2 IM adrenaline (1:1000) 10µg/kg colloid if hypotensive 10ml/kg nebulised salbutamol (5mg) dyspnea: adrenaline(1-2 m1 1:1ooo) aerosol anti-H1 iv prednisolone: 50 mg oral or iv Anaphylaxis: treatment (2) Gavalas M 1998 ( Ana 26)

  27. Plasma Epi. after sc/im injection min Simons FER 1998 (Ana 27)

  28. Grade 3 + 4: severe/life threatening ± skin manifestations ± vomiting; uncontrolled defaecation + severe bronchospasm, laryngeal oedema, cyanosis, respiratory arrest +/or clinical shock, impaired GCS, peri-arrest signs discontinue causative agent resuscitation room monitor patient; call for senior assistance maximal FIO2 ; IV access; IV adrenaline(1:10000 or higher) up to 5µg/kg; inject half dose slowly gross hypotension or GCS<8: fast iv colloids (20 ml/kg); repeat iv adrenaline anti-H1 iv prednisolone 100 mg iv Anaphylaxis: treatment (3) Gavalas M 1998 (Ana 28)

  29. Risks of iv adrenaline

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