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Anaphylaxis

Anaphylaxis. Dr. S. Parthasarathy MD., DA., DNB( anaes ), MD ( Acu ), Dip. Diab . DCA, Dip. Software statistics PhD ( physio ) Mahatma Gandhi medical college and research institute , puducherry – India . Definition .

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Anaphylaxis

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  1. Anaphylaxis Dr. S. Parthasarathy MD., DA., DNB(anaes), MD (Acu), Dip. Diab. DCA, Dip. Software statistics PhD (physio) Mahatma Gandhi medical college and research institute , puducherry – India

  2. Definition • Anaphylaxis is an acute reaction leading to severe physiologic derangements of multiple systems. • Follows the administration of allergen to a sensitized individual • True anaphylaxis denotes an IgE antibody- mediated reaction • Non IgE antibody- mediated reaction resembling anaphylaxis is anaphylactoid reaction

  3. Why should there be a name like that ?? • Inj TT – protects further tetanus disease • This is prophylaxis • Portierand Richet in 1902 reported that the second injection of sea anemone extract into dogs resulted in a fatal systemic reaction • Iron inj. -- First time – ok – on second injection It is fatal = antagonistic of prophylaxis – anaphylaxis

  4. Histamine release but not anaphylaxis • Morphine • Skin alone ?? • Atracurium • Skin and lungs also ??

  5. Why are some of us destined for a lifeof allergy and others not? • Low grade responders • Ige antibodies less with interferons • High grade responders • Ige antibodies more with cytokines

  6. Incidence in anaesthesia • It varies • 2 in 10,000 to 4.5 in 10000 • In france single institution study – 16 in 10000

  7. Clinical manifestationsof anaphylaxis • IV antigen ----= starts in 5 minutes • Other routes like oral • Slower and less rapid progression

  8. Clinical tips – may not be severe • Already asthmatic - • Already on beta blockers • Ill health

  9. Grades of clinical signs • Grade I presence of cutaneous signs; (10%) • Grade II as presence of measurable but not life-threatening symptoms including cutaneous effects, arterial hypotension(22%) • Grade III as presence of a life-threatening reaction, collapse , severe bronchospasm, arrhythmias ,(66 %) • Grade IV cardiac and/or respiratory arrest (4%)

  10. Anaesthesia • symptoms -- Cutaneous, respiratory, CVS, GI • Single system involvement – overlooked • During general and regional anesthesia or during deep sedation, cardiovascular signs predominate Epidural hypotension –give colloids – anaphylaxis to colloids --- Gloom ??

  11. Anaphylaxis under anaesthesiais not routine — most common triggers • It is not community anaphylaxis like – • Food stuff • Bee sting • Wasps • Snake bites • What happens in anaesthesia ?? • Unconscious !!

  12. Anaesthesia – confounding • During general anaesthesia, early symptoms of anaphylaxis such as tongue swelling, itch, breathing difficulty and wheeze • Skin lesions under the drapes

  13. Differential diagnosis • In a conscious patient, anaphylaxis is most easily confused with a vasovagal reaction, which may occur when a patient collapses after an injection or painful procedure • But there is a bradycardiain a vasovagal reaction

  14. Differential diagnosis • cold urticaria (especially if generalized), idiopathic urticaria, carcinoid tumors, and systemic mastocytosis. • Symptom based DD

  15. Who are prone ?? • Females • Previous anaphylaxis • patients with spina bifida or allergy to some fruit- latex allergy • IgA deficiency- blood and colloids

  16. TREATMENT OF ANAPHYLAXIS • Initial • Secondary

  17. Initial • Remove the offender • Venous tourniquet • Airway maintenance with 100% oxygen • laryngeal edema -- aerosolized epinephrine epinephrine by nebulizer (8–15 drops of 2.25% epinephrine in 2 mL normal saline) • Large bore IV lines • intravascular volume should be maintained with administration of isotonic crystalloid

  18. Rapid infusion of an initial bolus of 1–2 L intravenous fluid initially (20 mL/kg initially in children) before reassessment. • Adults may require 2–5 L.

  19. Epinephrine

  20. severe hypotension or airway obstruction • 0.1-mL (100μ g of a 1:1000 dilution) increments of epinephrine should be given intravenously, usually not exceeding 0.5 mg total. • Beware – halothane, stroke, infarction

  21. NO IV access • 0.3 mL of 1:1000 epinephrine can be given subcutaneously or intramuscularly, or 10 mL of 1:10,000 epinephrine can be administered through the endotracheal tube. • Hypotension and bronchospasm • Norad, dopamine infusions to follow

  22. Secondary • Antihistaminics – diphenhydramine • Ranitidine 1 mg/ kg • Steroids : hydrocortisone- 5 mg/kg (up to 200 mg initial dose) and then 2.5 mg/kg every 6 hours- methylprednisolone 1 mg/ kg initially and every 6 hours IV aminophylline infusion • Bicarbonate – controversial

  23. Refractory hypotension • Glucagon may be administered as a 1–5 mg (20–30 μg/kg in children, maximum 1 mg) dose over 5 min followed by an infusion of 5–15 μg/ min Recently – vasopressin

  24. Diagnosis • Mast cell tryptase • Postmortem collection of samples for assay is also possible • 2 tubes 5 – 10 ml – 6 hours gap within 48 hours means 4 deg • Or – 20 deg.

  25. Diagnosis • Immunodiagnostic Tests • Intradermal skin tests still are the most readily available and generally useful diagnostic tests for drug allergy. Total Serum IgE Levels • Assays to Measure Complement Activation • Blood and urine assay of histamine mediators • Radioallergosorbent Testing

  26. Perioperative environment

  27. NeuromuscularBlocking Agents • Suxamethonium • Pancuronium, atracurium, alcuronium

  28. Opioids • Histamine release is common Morphine and pethidine • anaphylaxis are rare • NSAIDs • Penicillin and betalactams, cephalosporins, septran • Skin test is almost foolproof to avoid it.

  29. Radiocontrast • Urticaria, angioedema, wheezing, dyspnea, hypotension, or death occurs in 2–3% of patients receiving intravenous or intraarterial infusions. Oral prednisolone, with AH prior to IV contrast

  30. Local anaesthetics • Genuine allergic reactions to local anaesthetic agents are extremely rare • Preservatives

  31. Colloids • Clinical anaphylaxis to all groups of colloids is possible, including gelatins (such as Haemaccel® and Gelofusine®), albumin, dextrans and starches. • Dextrans proved

  32. Methylmethacrylate • Episodes of hypotension , tachycardia reported • Whether anaphylaxis – proved ?? • Protamine • Diabetics – use insulin protamine

  33. Induction agents • Propofol was originally formulated in a vehicle containing Cremophor® EL but was reformulated as a lipid emulsion following reports of severe allergic reactions. Egg allergy ?? Thiopentone reported , methohexital – no

  34. Transfusion-RelatedAnaphylaxis In GA • Refractory unexplained hypotension • Haematuria

  35. Natural Rubber Latex • Children with spina bifida and urogenital anomalies • Gloves • Ambu bag • Reservoir bags • Masks • Latex injection ports • Tourniquets • Blood pressure cuffs

  36. Summary • Definition ,mechanism , incidence • Clinical manifestations • Differential diagnosis • Lab • Treatment • Anaesthetic factors and tips

  37. Thank you all

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