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ANAPHYLAXIS IN
ANESTHESIA
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HISTORY
The term anaphylaxis was coined by PORTER ANDRICHET in 1902
In greek prophylaxis means “protection”,
ANAPHYLAXIS means opposite protection Anaphylaxis generally occurs on re-exposure to a
specific antigen and requires the release of proinflammatory mediators but it can also occur on
first exposure because of cross reactivity amongcommercial products and drugs .
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GELL AND COOMB’S CLASIFICATION
ANAPHYLAXIS is a TYPE 1 reaction IgE mediatedhypersenstivity reaction
TYPE 2 reactions involve IgG Ig M and complement
mediated cytotoxicity TYPE 3 REACTIONS involve immune complex
formation and deposition leads to tissue damage
TYPE 4 reactions are delayed type hypersenstivity
reactions
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ANAPHYLACTOID REACTIONS
ANAPHYLACTOID REACTIONS occur through adirect nonimmune mediated reaction via release of mediators from mast cells and basophils but they present with symptoms similar to those of anaphylaxis
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SCOPE
Prevalence and incidence
Cause of perioperative anaphylaxis
Diagnosis
Management
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PREVALENCE
IT IS Difficult to determine incidence and prevalenceof anaphy.
Acc. To an estimate it is 1 in 3500 to 1 in 13000
Mortality 3-6 % Multiple drugs are administered during anesthesia
And because patients are under drapes early cutaneous symptoms are often unrecognized
no available diagnostic test with absolute accuracy
NMBA usually result skin test +ve for long time
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CLINICAL 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
compounds
5. underlying conditions
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EXTENT OF SIGNS OF ANAPHYLAXIS
In most cases
perioperative anaphylaxis is
characterized by cardiovascular
manifestation (73.6%),cutaneous symptoms(69.6%),and bronchospasm (44.2%) of cases.
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Time elapsed between administration andonset 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 orrecovery room
Colloid may cause immediate reaction or delay onset
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4.Previous allergies from drugsor related compound
Careful retrospective assessment of medical
history and record
Identify risk of patients during preanesthetic visit
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5.Underlying conditions
identified underlying condition can also help
to identify causative compounds
Atopic individual are at the risk of anaphylaxis
from NRL Mastocytosis,
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CLINICAL FEATURES
Cutaneous sym.
Flushing ,pruritus urticaria ,angioedema
G.it. Sym.
Nausea ,vomitting ,abdominal cramps ,diarrhoea Absent or difficult to differentiate in general
anesthesia , may be present in regional anesthesia orM.A.C.
Respiratory sym. rhinitis ,laryngeal edema,shortness of
breath,wheezing,respiratory arrest
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i
Increased peak inspiratory pressure, increased endtidal carbon dioxide ,decreased oxygensaturation,wheezing,bronchospasm
CARDIOVASCULAR SYM.
Tachycardia ,hypotension,cardiac arrythmias ,cardiovascular collapse
RENAL SYM.
Decreased Urine output HEMATOLOGIC SYM.
D.I.C.
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PATHOPHYSIOLOGY
On initial exposure IgE is produced and binds tomast cells and basophils
On reexposore multimeric antigen cross links two
IgE receptors initiating a signal transduction cascade Which culminates in increase of calcium and release
of mediators such ashistamine,proteases,proteoglycans,and P.A.F.
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TRYPTASE
Neutral 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
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ETIOLOGY
NMBAs – 69.2% succinyl choline ,rocuronium,atra.
NRL- 12.1% latex gloves
Antibiotics-8% penicillin,and beta lactams
Colloid- 3.7% dextran,gelatin Hypnotics-2.7% propofol,thiopentone
Opioids- 1.4% morphine ,meperidine
Local anesthetic agent- Miscellaneous -aprotinin,chymopapain,protamine,
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TREATMENT
DISCONTINUATIN OF DRUG OR ANESTHETIC
100% OXYGEN AIRWAY SUPPORT to incraseoxygen delivery and maintain airway
IV FLUIDS (2-4litres) for compensation of systemic vasodilation.
EPINEPHRINE is drug of choice because its alpha 1effects support the blood pressure and beta 2 effectsprovide bronchial smooth muscle relaxation
5-10micrograms initial bolus upto 100-500mic. For vascular collapse , start drip with 1 mic./min. forrefractory hypotension
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CONTINUED….
H1 blockers diphenhydramine 25-50 mg should beused early but their role is controversial once cardiacsym. Set in
H2 blockers ranitidine 150 ms bolus or cim etdine
400mg bolus should be added Bronchodilators eg.albuterol and ipratropium
bromide nebulizers
Corticosteroids decrease airway swelling andprevent recurrence of sym.as seen in protracted and
biphasic ana.hydrocortisone is preferred steroid because of fast onset
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CONTINUED……..
Extubation should be delayed .because airway swelling and inflamation may continue for 24 hours. Patient should be managed in I.C.U.
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PREVENTION
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MUSCLE RELAXANTS
NMBAs are most common cause of anaphylaxis Short acting depolarizing is at greatest risk
succinylcholine because it contains a flexiblemolecule that crossreacts link 2 mast cell IgEreceptors and induce mast celldegranulation
N.M.B. Induce 2 type of reactions
- IgE dependent => NH4+ main antigenic epitope - direct mast cell activation => benzylisoquinolinium
cisatracurium has lowest risk of mast cell activation
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Data controversy in rocuronium
Cross reactivity between NMBAs is 65% by skin test
and 80% by RIA
Pattern of cross reactivity vary between personCross 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
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PREVENTION
Avoid NMBAs for patient with previoushistory to reation in future
anesthesia whenever possible
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LOCAL ANASTHETICS
vasovagal responses ,tachycardia,lighthededness orMetallic taste , perioral numbness can result fromintravascular injection of local anesthetic orepinephrine
Anaphylaxis is very rare, type 4 reaction is mostcommon
Amide-rare , ester< 1% for anaphylaxis
Ester metabolite=> PABA usually cause
type I reaction
Preservative => methylparaben
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HYPNOTICS
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
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OPOIDS
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
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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
challenges may be required to
diagnose opioid allergy
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NATURAL RUBBER
Divided into 2 groups
- atopic
- significant exposure=>HCP, Neural tube
defect 20% of perioperative anaphylaxis
Use questionaire
Rx => avoidance
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% of perioperative anaphylaxis
20% severe reaction
20 min after administration
Gelatin allergy - Skin test (phadiac 74,BAT
HES
- skin test
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rextran => DIAR
- IgG immune complex dis
- prevent by hapten dextran (1Kd) infusion
- skin test is not established Albumin anaphylaxis is anectodal case
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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
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OTHER AGENTS
Hyaluronidase
Oxytocin
dyes
Aprotinin Protamine and heparin
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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
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cardiac
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cardiaccatheterization
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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
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