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Objectives

Objectives. To emphasize the importance of not missing the diagnosis and not under-reporting the events To remind our department about the available anaphylaxis investigation protocol and help implement it in sites that don’t currently have it available

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Objectives

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  1. Objectives • To emphasize the importance of not missing the diagnosis and not under-reporting the events • To remind our department about the available anaphylaxis investigation protocol and help implement it in sites that don’t currently have it available • To step back and analyze the efficiency of our protocol. How can we improve it?

  2. Structure • 2 Clinical cases • Considerations in anesthesia • Definition, clinical signs, epidemiology and common causative agents • Diagnostic tests • New information on specific drugs • ANAPHYLAXIS INVESTIGATION - how others do it and where we can improve

  3. Clinical case 1 • 38 year old male • Elective laparoscopic cholecystectomy • GERD, mild asthma, obese • No previous GA • No known allergies

  4. Clinical Case 1 • Midazolam, Fentanyl, Propofol, Lidocaine, Rocuronium, Ancef • 5 min: profound hypotension • No rash, no wheeze • Good response to Epinephrine

  5. Clinical Case 1 INVESTIGATIONS AND FOLLOW UP • Tryptase (19mcg/L) • Allergy consult 6/52 later • ? False positive intradermal test for Rocuronium

  6. Clinical Case 2 • 25 year old male • Pinning of fractured metacarpal • Healthy • No known allergies • IV started • Monitors attached

  7. Clinical Case 2 • Sudden onset tachycardia • LOC • Pruritis • Empty bag of Cefazolin • Rash • Severe hypotension • Good response to epinephrine and IV fluid

  8. Clinical Case 2 FOLLOW UP • Blood work according to protocol • Referral for allergy consult RESULTS • Tryptase (46mcg/L) • No consult note on netcare

  9. Anaphylaxis in Anesthesia - usually not a “open-and-shut case” • multiple drugs • common cardiovascular responses to anesthesia are also manifestations of anaphylaxis • position changes • insufflation • underlying systemic disease might mask the presence of anaphylaxis • no rash/patient covered • delayed reactions

  10. Anesthesia and Anaphylaxis • anesthetic drugs • antibiotics • blood products • heparin • polypeptides (latex, protamine) • IV volume expanders • antiseptics (chlorhexidine and betadine)

  11. Anaphylaxis - Definition • Classic: Pathophysiological definition • Now: Clinical Any severe systemic hypersensitivity reaction of rapid onset, which may cause death or other adverse outcomes • “Anaphylactoid” - outdated

  12. Clinical manifestations of Anaphylaxis in Anesthesia

  13. Epidemiology • 1 in 10 000 - 20 000 anesthetic procedures • France: 1 in 13 000, 1 in 6 500 with NMBA • Mortality: 3.4% • Edmonton: 31 cases over 7 years 20 000 anesthetics/year 1 in 5 000

  14. Common causative agents • Antibiotics • NMBA’s • Latex • Geographical variation

  15. Common causative agents - NMBA’s • Reaction without previous exposure • Quaternary ammonium ions • Commonly used chemicals might sensitize patients • Pholcodine in France and Norway • Cross-reactivity 60 - 70%

  16. How to diagnose perioperative anaphylaxis

  17. How to diagnose perioperative anaphylaxis SECOND EVIDENCE (Biological) PRIMARY investigations - histamine - tryptase (initial and baseline) SECONDARY investigations - IgE assays

  18. How to diagnose perioperative anaphylaxis • IgE assay specific for succinylcholine • The other NMBA: markers with similar epitopes are used • PAPPC vs Allergen c261 Pholcodine

  19. How to Diagnose Anaphylaxis THE GOLD STANDARD THIRD EVIDENCE: SKIN TESTS • Detects IgE mediated reactions • Important tool to identify and avoid culprit substance • 6 weeks before testing • ALL drugs and substances • Positive and negative controls

  20. Propofol and egg allergy

  21. Propofol and egg allergy • Retrospective chart review • 42 patients with egg allergy received Propofol • 1 allergic reaction in a boy with history of anaphylaxis to eggs

  22. Antibiotics and cross-reactivity • “Penicillin allergy” is common • Cephalosporin antibiotics are popular with surgeons • How likely is cross-reactivity? • Clinical practice based on old case reports • More recent publications

  23. Antibiotics and Cross-reactivity • What if my patient really needs a ß-lactam antibiotic? • 85% of “penicillin allergic patients” have negative skin tests. • Caution: history of anaphylaxis • Graded dose escalation

  24. Opioids • True allergy is rare • Side effect v.s. Pseudo-allergy v.s. Real allergy • Cross reactivity amongst different structural classes • Thorough allergy history before analgesic plan

  25. The chemical classes of Opioids • PHENYLPIPERIDINES: miperidine, fentanyl, sufentanil, remifentanil • DIPHENYLHEPTANES: methadone, propoxyphene • MORPHINE GROUP: morphine, codeine, hydrocodone, oxycodone, oxymorphone, hydromorphone, nalbuphine, butorphanol, levophanol, pentazocine

  26. Latex and food allergy

  27. Anaphylaxis Investigation • Australia, France and England have country wide guidelines • Edmonton: 1 of 2 centers in Canada with a formal protocol • No need to reinvent the wheel • CAS for country wide guidelines

  28. The French Guidelines • 2005 • French Society for Anesthesia and Intensive care

  29. French Guidelines RESPONSIBILITIES OF THE ANESTHETIST: • Initiate investigation • Inform patient • Report the event

  30. French Guidelines: follow-up • Written report from allergist • Conclusion, recommendations • Document to patient • Bracelet, medic-alert warning

  31. Levels of anaphylaxis follow-up1) Anesthesia • Referral for allergy consultation - complete history is important • Informing patient • “Allergy letter” to patient and family doc • Who should be responsible for follow-up?

  32. Levels of anaphylaxis follow-up1) Anesthesia STATISTICS: • 31 cases • 10 allergy consultations • 6 confirmed allergies - 3 to latex - 2 to Ancef - 1 to Bacitracin

  33. Levels of anaphylaxis follow-up2) Allergologist • Faxed consult, no closed-loop communication • Contacting patients • Availability of report • Closer collaboration needed

  34. Levels of Anaphylaxis follow-up3) The Laboratory • Various laboratories involved • Results hard to find

  35. Conclusions • It is important to diagnose and follow-up on peri-operative allergic events • Revision of current protocol and possible nationwide guidelines would might be a realistic aim for the future • Better collaboration between Anesthesia and Allergology is needed • Patients need to leave the hospital with a letter and information about their potential allergy, which should be updated as information becomes available

  36. THANK YOU & QUESTIONS • Dr J Lujic • Dr E Bishop

  37. References • Levy JH, Adkinson NF. Anaphylaxis During Cardiac Surgery: Implications for Clinicians. Anesthesia Analgesia 2008;106:392-403 • Hepner DL, Castells MC. Anaphylaxis During the Perioperative Period. Anesthesia Analgesia 2003;97:1381-95 • Murphy A, Campbell E, Baines D, Mehr S. Allergic Reactions to Propofol in Egg-Allergic Children. Society for Pediatric Anesthesia, Anesthesia Analgesia 2011;113:140-4 • Gurrieri C, Weingarten TB, Martin DP et.al. Allergic Reactions During Anesthesia at a Large United States Referral Center. Anesthesia Analg 2011;113:1202-12 • AAGBI Safety Guideline - Suspected Anaphylactic Reactions Associated with Anaesthesia. The Association of Anaesthetists of Great Britain and Ireland. July 2009

  38. References • Mertes PM, Laxenaire MC, Lienhart A. Reducing the risk of anaphylaxis during anaesthesia: guidelines for clinical practice. J Invest Allergol Clin Immonol 2005; Vol. 15(2): 91-101 • Dewachter P, Mouton-Faivre C, Emala CW. Anaphylaxis and Anesthesia, controversies and New Insights. Anesthesiology 2009; 111:1141-50 • Analgesic Options for Patients with Allergic-Type Opioid Reactions. Pharmacist’s Letter. February 2006 - volume 22 - Number 220201 • ImmunoCAP Allergen c261 Pholcodine. www.immunocapinvitrosight.com. April 2009 • Fisher MM, Jones K, Rose M. Follow-up after anaesthetic anaphylaxis. Acta Anaesthsiol Scand 2011;55: 99-103

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