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Michael rose on anaphylaxis

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Information about Michael rose on anaphylaxis
Health & Medicine

Published on September 1, 2013

Author: oliflower

Source: slideshare.net

Description

This is a presentation on anaphylaxis by Michael Rose. Michael is an anaesthetist in Sydney and a leading expert in the world of anaphylaxis. He talks about the basics and recent developments in this field - an area of critical care relevant to us all.
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Dr Michael Rose Director, RNSH AnaestheticAllergy Service Chair,Australian and New Zealand AnaestheticAllergy Group (ANZAAG) Chair,ANZCA AnaestheticAllergy Subcommittee Member,Australasian Society of Clinical Immunology and Allergy (ASCIA) rnsaac@gmail.com Anaesthetic anaphylaxis July 2013

Bad days don’t always come with a warning..

Once upon a time…. Elective anaesthesia was dangerous….. Death/ morbidity due to : Older drugs Less emphasis on surgical anaesthetic audit / CPD Lack of patient workup/information Poorer monitoring Airway emergencies Anaphylaxis MH Now, otherwise healthy patients “expect” to make it through without problems

Anaesthetic emergencies Now….Anaphylaxis one of the most prominent causes of unanticipated sudden catastrophe Incidence of : MH: 1:50,000 -1:100,000 CICO: 1:12,500 - 1:50,000 Anaphylaxis under anaesthesia: 1: 4,500 -1:10,000

What is anaphylaxis ? Anaphylactic vs. anaphylactoid now obsolete terminology Clinical anaphylaxis - the presence of the following Skin or mucosal changes – rash (erythema/urticaria) , peau d’orange, angioedema Plus one of… Cardiovascular instability (hypotension, variable HR changes) Respiratory insufficiency – bronchospasm, low sats GIT issues – pain, vomiting, diarrhoea Sampson HA, Muñoz-Furlong A, Campbell RL, Adkinson NF et al. Second symposium on the definition and management of anaphylaxis: Summary report—Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium. J Allergy and Clin Immunol 2006 ;117(2): 391-397

Severity Grading 1. Cutaneous Signs 2. Moderate multi-organ involvement Includes hypotension, severe tachycardia, bronchial hyper- reactivity 3. Severe multi-organ involvement Includes severe bronchospasm, arrhythmias, cardiovascular collapse 4. Cardiac and or respiratory arrest 5. Death (bad, lots of paperwork)

What makes anaesthetic anaphylaxis different from food anaphylaxis ?  Often sudden onset and severe IV administration of antigen generally (except chlorhex/dyes/latex)  Often other things occurring that may mimic anaphylaxis  Insufflation of peritoneum  Cardiac ischaemia  Haemorrhage  Intubation (bronchospasm)  Skin reaction often not seen at time or at all  Gastrointestinal symptoms not prominent/noticed

As a result… Delayed/missed diagnoses Unnecessary investigations

Anaesthetists or Immunologists?? Differing experiences of anaphylaxis Differing approaches Collaboration useful ANZAAG has the best of both worlds www.anzaag.com

What do we do? History: of event from notes/anaesthetist/patient Results of already conducted investigations (e.g. MCT, sIgE) Skin testing Intradermal (standard +/- stronger “validated” concentrations) Skin Prick Serum tests Baseline MCT SIgEs (“RASTs”) Morphine/pholcodine for NMBAs Chlorhexidine Latex Antibiotics IV Challenge The 1st year registrar 2am test….

Red flags of difficult cases Poor information / documentation Not referred directly from the anaesthetist involved Vague descriptions of events (mild hypotension, possible rash) No MCTS High normal or completely normal MCTs with a good clinical picture Severe atopy and dermatographism

Causes – RNSAAC 2007-2013 1. NMBAs 2. Antibiotics 3. Chlorhexidine 4. Colloid 5. Patent Blue 6. (Local Anaesthetics – often type 4 hypersensitivity)

Muscle relaxant Cross-reactivity Probably around 60% have at least one other NMBD cross-reacting Some have multiple Not entirely predicable by class/structure Do not substitute without testing results!!

www.anzaag.com

Other ANZAAG resources

Mast cell tryptases • Samples: • First sample when situation under control (ideal 60 mins) • 2nd sample 4 hours • 3rd sample 24 hours or later • The ‘delta’ tryptase from peak to baseline often most informative • Serum tube 5-10mls, labeled with time of sample • Cooled to 4 degrees if delay / transport • Post mortem samples can be useful in sudden unexplained death

What’s topical Chlorhexidine Pholcodine Patent Blue When to test?????? Who should test (? all anaesthetists/intensivists)

Chlorhexidine Catheter lubricant Central lines Mouth washes and lozenges Skin preps Alcohol/chlorhexidine wipes Risk versus benefit of making them mandatory

Australia No central database, but many reports of increasing incidence NZ Some centres report their cases of allergy to a central body, the Centre for Adverse Reactions Monitoring (CARM) In the 43 years from 1965 until April 2008, CARM had 54 reports of chlorhexidine reactions. Four years later, by April 2012, these numbers had almost doubled to 100 reports The Problem

Latex allergy – Widespread in hospital products Not just perioperative Often delayed onset of reaction Concern after reactions increased after widespread use of latex products occurred Less of an issue now with labeling and alternatives Sound Familiar?

 Blood collectors  Radiology procedures  ICU  Emergency department  General ward staff The solution requires…

A Chlorhexidine formulary list From St George Hospital Sydney

30

Widespread use of chlorhexidine as an antiseptic Clearly an effective antiseptic Broad spectrum Persistent effect in skin “One size fits all” approach Controversies

www.chlohexidinefacts.com

Texas Childrens Hospital 2004 – Chlorhexidine routinely used on CVC dressing changes 2005 – Chlorhexidine mouthwashes daily for AML patients qacA/B gene emerged in 2006 10% of MRSA 2009 22% of MRSA 2011 Resistance

Japan Issued a prohibition of chlorhexidine use on mucosal membranes in 1984 USA FDA issued a warning about increasing incidence of allergy from impregnated CVCs and other products in 1998 Warnings

Moves by health departments toward recommending chlorhexidine for all procedures Good evidence for effectiveness of chlorhexidine on long duration lines (CVCs) No good evidence of benefit for short duration peripheral access Chlorhexidine baths pre-op? Chlorhexidine policy

Chlorhexidine anaphylaxis is increasing Be prepared to treat chlorhexidine allergic patients Be extra vigilant dealing with known chlorhexidine allergy patients Risk versus benefit Still remains the most effective antiseptic Rethink use of chlorhexidine for low infection risk Develop a chlorhexidine – free

Case discussions • 24yr male • Anaphylaxis under anaesthesia for fundoplication • Cardiac arrest, rash, angioedema • Treated promptly with adrenaline (bolus and infusion) and IV fluid • MCT 126mcg/L

Case 1 continued • Skin tested - Positive to Rocuronium Cross reactive to • Suxamethonium • Cisatracurium • Pancuronium Negative to Vecuronium Subsequent safe anaesthesia with same induction drugs and vecuronium

Case 2 25 year old male Metastatic bowel cancer Has hemicolectomy and chemotherapy to reduce peritoneal and hepatic disease Port inserted for chemo

Case 2 continued During chemo Multiple episodes of minor anaphylaxis from swabbing over port site before accessing One episode of anaphylaxis after an infusion line was swabbed before piggy-backing a chemo solution ……….Unrecognised

Then… GA for peritonectomy/liver resection Massive anaphylaxis after a chlorhexidine coated CVC is inserted through chlorhexidine/alcohol prep Cardiac arrest Resuscitated Subsequently tested positive to chlorhexidine on intradermal, skin prick and sIgE tests

Subsequently Meeting involving theatres, radiology, ICU about how to manage this patient and his multiple investigations without exposure to chlorhexidine Chlorhexidine - free protocol developed

Case 3 42 yr male Percutaneous lithotripsy Anaphylaxis post induction – fentanyl/propofol/Keflin/clonidine/dexamethasone Hypotension to 60mmHg plus rash Required 500mcg total IV dose of adrenaline Single MCT done intraoperatively (? Time)  elevated (15.9 mcg/ml) Postop-course complicated by bleeding. Given cephalexin as part of treatment – caused severe red itchy rash Intradermal testing at normal/higher concentrations negative to all, including cephalothin

Case 3 cont. Represented for testing on a second occasion. Still negative to all tested meds But What if Keflin (cephalothin) was actually cephazolin?? Tested positive intradermally and SPT to cephazolin

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