Intraoperative Anaphylaxis

Angelique Davis

Hypersensitivity Reactions Type I

• IgE or Non-IgE Allergic reaction Type II

• IgG, IgM, Complement mediated• Cytotoxicity; Blood reaction

Type III• Immune complex response• Clumps form due to not enough antibody to rid

antigen. Lupus, rheumatoid arthritis Type IV

• Delayed; T-cell mediated response• Bone marrow transplant rejection: Graft vs Host

Type I Hypersensitivity reaction

ANAPHYLAXIS ANAPHYLACTOID

IgE mediated Previous exposure to

allergen Can occur once in every

5,000-10,000 anesthetics More frequent and more

severe Occurs within seconds to

5-10 minutes May be delayed onset

10-12 hours

Non-IgE mediated Can occur and act like

IgE mediated anaphylaxis upon first exposure to allergen

Idiopathic Less frequent Difficult to distinguish

between the two when reaction occurring

Pathophysiology

Pathophysiology Primarily concerned with mast cells

and basophils, which are mostly found in the heart, vasculature, respiratory, GI tract, and integument

Histamine release • Mucous secretion, edema, vasodilation,

tachycardia, inflammation, cardiac depression Leukotriene and prostagladin release

• Bronchoconstriction, angioedema, increased vascular permeability

Early signs and symptoms Pruitis Malaise Dizziness Flushing Erythema Uticaria Angioedema

Can anyone tell me why these signs may be difficult to recognize?

Late Signs and SymptomsRESPIRATORY CARDIOVASCULAR

Wheezing Hypoxia Hypercarbia Angioedema High peak

pressures

Hypotension Tachycardia Dysrhythmia's Shock Death

Differential Diagnosis Bronchospasm Malginant Hyperthermia Laryngospasm Asthma Drug overdose Pulmonary Edema Pneumothorax Venous Air Embolism Pericardial tamponade Rapid infusion of vancomycin causes

flushing (red man syndrome)

The Culprits Neuromuscular blocking

agents:• Succinylcholine at 33.4%• Rocuronium at 29.3%• Atracurium at 19.3%• Vecuronium at 10.2%

Due to the quaternary ammonium ions cross-sensitivity similar to the those in cosmetics, personal products, and drugs.

The Culprits, con’dANTIBIOTICS LATEX

Beta-lactum Antibiotics• Penicillin's• Cephalosporin's

Vancomycin Quinolones

Latex containing gloves Catheters Tourniquets

More common in individuals that have had multiple surgeries in the past

Treatment Remove causative agent Call for help Intubate or maintain airway 100% FiO2 Epinephrine 1:1,000 (α1, α2, β1, β2) Albuterol (β2 agonist) Fluid management (0.9% NaCl or colloid-

controversial) Histamine blockers (H1, H2) Corticosteroids

Treatment Guide

Emergency drug trayEpinephrine

Phenylephrine

Diphenhydramine

Standard Drug Tray

Famotidine

Dexamethasone

Albuterol inhaler

Refernces Butterworth IV, J. F., Mackey, D. C., & Wasnick, J. D. (2013). Anesthetic

Complications. In Morgan & Mikhail’s Clinical Anesthesiology (5th ed. (pp. 1199-1229). New York, NY: McGraw-Hill.

Ebo, D. G., Fisher, M. M., Hagendorens, M. M., Bridts, C. H., & Stevens, W. J. (2007). Anaphylaxis during anesthesia: diagnostic approach. Allergy,

62, 471-487. Jacobson, J., Lindekaer, A. L., Ostergaard, H. T., Nielsen, K., Ostergaard, D.,

Laub, M., ... Johannessen, N. (2001). Management of anaphylactic shock evaluated using a full-scale anesthesia simulator. ACTA Anaesthesiologica Scandinavica, 45, 315-319.

Mertes, P. M., Tajima, K., Regnier-Kimmoun, M. A., Lambert, M., Iohom, G., Gueant-Rodriguez, R. M., & Malinovsky, J. M. (2010, July).

Perioperative Anaphylaxis. Medical Clinics of North America, 94(4). Norred, C. L. (2012). Anesthetic-Induced Anaphylaxis. AANA Journal, 80,

129-140. O’Donnell, M. P. (2014). The Immune System and Anesthesia. In J. J.

Nagelhout, & K. L. Plaus (Eds.), Nurse Anesthesia (5th ed. (pp. 1015-1035). St. Louis, MO: Elsevier.