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Anaphlaxis

Learn about the pathophysiology, clinical signs, and treatment options for anaphylaxis. Explore the specific pharmacological and supportive treatments available.

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Anaphlaxis

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  1. Anaphlaxis Dr Ferdi Menda

  2. Learning Objectives • 1. The pathophysiology of anaphylaxis • 2. Clinical signs of anaphylaxis • 3. Differential diagnosis of anaphylaxis • 4. Spesific pharmacological and supportive treatment of anaphylaxis

  3. Anaphylaxis • A severe life threatening (Type I) immediate hypersensitivity reaction. • The reaction occurs when the person reexposed to an ‘allergen’, which leads to IgE Ab during previous exposure.

  4. Anaphylaxis • Injected, inhaled or ingested substance –usually drugs, food, insect venom- can serve as the allergen itself.

  5. Anaphylaxis • During 1st exposure, mast cells (A)-allergen (B) complex secrete IgE (C) antibodies. • Some of these IgE remain attached to the mast cells. • During the 2nd exposure allergen combines with IgE on the surface of the cell & release inflammatory mediators.

  6. Anaphylaxis • Allergen: • IgE + Ag Mast cells, basophils: • Histamin, triptase, leukotriens, eosinophilic chemotactic factors are released. • IgG leads to “complemant” system activation.

  7. Anaphylaxis • Non-Allergic (non-IgE, non-immun): • Reaction is developed by means of direct pharmacologic, toxic stimulus of the mast cells & basophils; Inflammatory mediators are released.

  8. Uniphasic Anaphylaxis Treatment Initial Symptoms Time 0 AntigenExposure

  9. Biphasic Anaphylaxis Treatment Treatment 1-8 hours Second-Phase Symptoms Initial Symptoms Classic Model Time 0 1-72 hours New Evidence AntigenExposure

  10. Protracted Anaphylaxis Initial Symptoms 0 Time Possibly >24 hours Antigen Exposure

  11. Anaphylactoid reaction • An identical or very similar clinical response (skin reaction) which is not mediated by IgE, or an Antigen-Antibody process.

  12. Anaphylaxis during Anesthesia • Anaphylaxis incidence during anesthesia is:1/5.000-1/20.000 • Multiple drug use duing general anesthesia may mask the symptoms. • Diagnosis during anesthesia is DIFFICULT !

  13. Agents responsible for anaphylaxis during Anesthesia • Non-depolarizing neuromuscular blockers • Latex & antibiotics • Colloid solutions, barbituric acid • All drugs & agents used during surgery or anesthesia may be responsible • Mind the solutions or drugs used by the SURGEON !!

  14. Cerrahın kullandıklarına DİKKAT !! • Topical, infiltration Local Anesthetic agents (<%1 anaphylaxis) • Irrigation solutions • Latex • Disinfectant • Markers (patent blue)

  15. Mast cell activation, degranulation GIS Respiratory system Airway CVS SKIN Increased peristaltism Nausea, vomiting Bronchospasm, Upper airway edema Hypotension, tachycardia, arrhytmia, collaps Erythema Urticaria Edema HYPOVOLEMIA; Deep general anesthesia; Deep regional anesthesia may mask the symptoms.

  16. SKIN Erythema Urticaria Edema

  17. UPPER AIRWAY Stridor Hoarseness Angioedema Sneezing

  18. Respiratory system Wheezing Dyspnea Normal Airway Airway inflammation Bronchospasm & mucus production

  19. Cardiovascular symptoms arrhythmias

  20. Gastrointestinal symptoms • Nausea, vomiting, • Diarrhea, • Abdominal cramp like pain: uncommon except with food allergies.

  21. Anaphylaxis: • Generally occurs immediately after drug injection (2-15 mins). • Generally related to iv agents. • Rarely occurs 2.5 hour after the drug therapy. • No death reports > 6 hours after the reaction. • Reaction time following oral drug intake is unpredictable ?

  22. Anaphylaxis therapy* • STOP the responsible agent • Call for HELP • Warn the SURGEON • Trandelenburg position • Ventilation+%100 O2 • Fluid therapy: 500-1000 mL iv adult, ≥20 mL/kg çocuk (%09 NaCl, RL) * Kroigaard M. Scandinavian Clinical Practice Guidelines on the diagnosis, management and follow-up o anaphylaxis during anaeshesia. Acta Anaesthesiol Scand 2007 + ERC 2010.

  23. ADULT: Severe anaphylaxis 0.1-1 mg iv 0.5-0.8 mg im Mild rxn: 10-50 micg iv PEDIATRIC Severe anaphylaxis 0.01 mg/kg iv 5-10 micg/kg im Mild rxn: 1-5 micg/kg iv Anaphylaxis therapy: ADRENALIN* * Kroigaard M. Scandinavian Clinical Practice Guidelines on the diagnosis, management and follow-up o anaphylaxis during anaeshesia. Acta Anaesthesiol Scand 2007.

  24. Anaphylaxis therapy: ADRENALIN* IV ADRENALIN: ADULT: 50 micg titrate, PEDIATRIC: 1 micg/kg. * ERC anaphylaxis guidelines 2010.

  25. Epinephrine Injection: IM vs. SQ Simons et al:Prospective, randomized, blinded study in children T-max was 8 ± 2 minutes after injection of epinephrine 0.3 mg from an EpiPen IM in the vastus lateralis vs. 34±14 minutes (range, 5 to 120) after injection of epinephrine 0.01 mg/kg SQ in the deltoid region.

  26. Epinephrine Absorption: SQ vs. IM Simons FER et al. J Allergy Clin Immunol 1998;101:33-7.

  27. CORTICOSTEROID Adult HIDROCORTISON 250 mg, M.Prednisolon 80 mg iv Pediatric HIDROCORTISON 50-100 mg, M.Prednisolon 2 mg/kg iv Anaphylaxis: Segondary therapy ? • Antihistaminic: • Adult • Promethazin 50 mg iv • Pediatric • Promethazin 0.3-1 mg/kg iv/im Bronchospasm: nebulised β2-agonist. Not a 1st choice therapy.

  28. Anaphylaxis: Unresponsive to Adrenaline ! • NORADRENALIN: 0.05-0.1 mcg/kg/min • VASOPRESSIN : 2-10 IU iv doses until response. • GLUCAGON:1-2 mg iv doses until response (in patients taking beta-blocker & unresponsive to high dose adrenaline).

  29. Patients having anaphylactic rxn previously with • Polen, animal fur, dust atopy • Former prolonged latex exposure may develop reaction with LATEX.

  30. RECOMMENDATIONS • Anaphylaxis with Local Anesthetics is RARE; prefer Regional or local anesthesia. • Agent of choice for General anesthesia is VOLATILE. “No Anaphylaxis is reported” • AVOID Latex & Neuromusculer blockers ! • Antihistaminic/steroid premedication does not prevent “anaphylactic shock” ? • If known to cause a previous reaction, avoid using that drug/agent.

  31. Follow-up • After a moderate-severe anaphylactic rxn: • Follow-up with blood (triptase), then skin test. • Skin test: skin prick, intradermal test (IgE) or • If there is a local or disseminated urticeria related to Chlorhexidin skin test is necessary. • Follow-up is not necessary: • Erhythema around the injection site, isolated bronchospasm in patients with previous bronchial reactivity.

  32. When we decide an Alergy test, the following should be reported: • Symptoms • Severity of the reaction • Onset time and length of the reaction, • Therapy • All the agents used before the reaction • Anesthesia form, notes • Fill the advers event form.

  33. Primary evaluation • Serum triptase & IgE Ab. Blood sample for analysis must be drawn within 1-4 hrs following the rxn. 5-10 mL blood, serum. The timing of the blood sampling after the reaction should be noted ? • Control blood sample should be drawn before Anaphylaxis or 24 hrs after the reaction. • Blood for IgE analysis can be sampled within 6 months after the reaction.

  34. Secondary evaluation Skin test: • Evaluates mast cell rxn by IgE. Salin (-) control, Histamin (+) control. Test has to be done 6 weeks after the reaction. • Bir NMBA ile (+) sonuç alındıysa, diğer NMB test edilmeli. • Bir LA rxn varsa diğerleri test edilmeli. Cross reactivity. Drug provacation test: RISKY ! • It has to be performed after the skin test. Generally 1/10 of the therapeutic dose of the drug responsible for the reaction is given via same route.

  35. Frequently used agents during Anesthesia • NMBA. (skin prick test “gold standart”) • 1/5.000-10.000 (france,norway,GB). • Other countries 1/50.000-1/150.000. • Latex (<5-17.7%) • Antibiotics. (Penicillin 0.1%) • 15% of all the Anaphylactic rxns • Chlorhexidin. • 12% of all the rxns during anesthesia are related to it (in denmark). • Gelatin (4%-france). HES (0.006%)

  36. Frequently used drugs during Anesthesia • Ketamine, Midazolam. Very rare. • Opioids. Low incidance. • L.Anesthetics. Very low. • Propofol. (2.3%) Rare. • Thiopental. 1/23.000-29.000 (higher in female) • NSAID. (general population 1%) rarely a problem during anesthesia. COX-2 inhibitors may be safer ?

  37. WARN the patient • Bracelet • Detailed epicrisis

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