Published on September 1, 2013
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) email@example.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!!
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
Widespread use of chlorhexidine as an antiseptic Clearly an effective antiseptic Broad spectrum Persistent effect in skin “One size fits all” approach Controversies
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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