perioperative anaphylaxis

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  • 1. Peri-operative anaphylaxis w. pongsak
  • 2. scope Prevalence and incidence Cause of perioperative anaphylaxis Diagnosis Management
  • 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
  • 4. other opioid colloid hypnotics 4% 1% 1% 3% ATB 15% NMBAs 59% NRL 17%
  • 5. 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
  • 6. 1.Extent of sign of anaphylaxis In most cases perioperative anaphylaxis is characterized by severe respiratory and cardiovascular manifestration !
  • 7. 2.Drugs and related compounds The most common is NMBAs Others are latex, antibiotics
  • 8. 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
  • 9. 4.Previous allergies from drugs or related compounds Careful retrospecive assessment of medical history and record Identify risk of patients during preanesthetic visit
  • 10. 5.Underlying conditions itentified underlying condition can also help to identify causative compounds Atopic individual are risk of anaphylaxis from NRL Mastocytosis, HAE
  • 11. tryptase Neural serine proteinase Mature -tryptase reflect mast cell activation Pro -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
  • 12. etiology NMBAs NRL Antibiotics Colloid Hypnotics Opioids Local anesthetic agent miscellaneous
  • 13. 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)
  • 14. aminosteroid
  • 15. benzylisoquinolinium
  • 16. 9% 3% 1% 20% 44% 23% rocuronium succinylcholine atracurium vacuronium pancuronium other
  • 17. 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
  • 18. Rocuronium :high risk anaphylaxis British j anasthesia 2001: 86; 678-82
  • 19. 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.
  • 20. 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%
  • 21. Avoid NMBAs for such patient in future anesthesia whenever possible!
  • 22. Local anesthetic agents divide into benzoic acid esters and amide
  • 23. 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
  • 24. 1.181 1.181
  • 25. Challenge test remain the gold standard !
  • 26. 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
  • 27. 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)
  • 28. 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
  • 29. NRL Devide into 2 group - atopic - significant exposure=>HCP, Neural tube defect 20% of perioperative anaphylaxis Use questionaire Rx => avoidance
  • 30. Plasma volume expanders 4% of perioperative anaphylaxis 20% severe reaction 20 min after administration Gelatin allergy - Skin test (phadiac74) , BAT HES - skin test
  • 31. Drextran => DIAR - IgG immune complex dis - prevent by hapten dextran (1Kd) infusion - skin test is not established Albumin anaphylaxis is anectodal case
  • 32. 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
  • 33. Other agent Hyaluronidase Oxytocin dyes Aprotinin Protamine and heparin
  • 34. 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
  • 35. 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
  • 36. 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
  • 37. Thank you for y