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Anaphylaxis during the perioperative period11/4/2009
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A healthy male had propofol, succinylcholin, and rocuronium during a back surgery. He developed hypotension but no respiratory or skin symptoms. BP normalized with epi. Plasma histamine was elevated but tryptase normal. Surgeon wants pt to be skin tested and see which agent caused the problem. Is this a true allergic reaction? Is there a standard protocol for skin test to these agents? |
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Thank you for your recent inquiry.
Yes, this could be a true allergic (IgE mediated) reaction, and there are a number of well-established protocols for testing to these drugs. The first thing that you might like to do, however, is look at a review of the issue of anaphylaxis during the perioperative period. One such review is readily available online at no charge. The reference is:
Hepner DL and Castells MC. Anaphylaxis during the perioperative period. In: Anesthes analg 2003; 97:1381-1395 (International Anesthesia Research Society). You can actually reach this reference by simply "Googling" "anaphylaxis during the perioperative period." This article cites a number of references which you can obtain by simply "clicking" on the specific reference number at the end of the article. This should also pull up specific protocols for skin testing.
A very helpful reference which does give details regarding skin testing is as follows:
Ebo DG, et al. Scandinavian clinical practice guidelines on the diagnosis, management, and follow-up of anaphylaxis during anesthesia: some diagnostic issues. ACTA Anaesthesiol Scand 2007, July; 51(6):655-670.
Another excellent article in this regard was also written by the same first author (Ebo), and can be found in Allergy 2007, May; 62(5):471-487. It is entitled "Anaphylaxis during anesthesia: diagnostic approach."
These articles should certainly be of help to you in evaluating your patient.
Thank you again for your inquiry and we hope this response is helpful to you.
Abstract:
Anaphylaxis to muscle relaxants: Rational for skin tests
Auteur(s) / Author(s)
MONERET-VAUTRIN D.-A. (1) ; KANNY G. (1) ;
Affiliation(s) du ou des auteurs / Author(s) Affiliation(s)
(1) Université Nancy 1, Hospital Central, Department of Internal Medicine - Clinical Immunology and Allergy - Avenue du Marechal de Lattre-de-Tassigny, 54035 Nancy, FRANCE
Résumé / Abstract
IgE-dependent allergy to muscle relaxants (MR) has an estimated prevalence of 1 out of 6500 General Anesthesias (GA). 62% of anaphylaxis during surgery are due to MR anaphylaxis. All the molecules are divalent, carrying two NH4+ epitopes (quaternary ammonium ions), either structurally or after rapid in vivo protonization (vecuronium). The excellent overall performance of skin test makes them the golden standard for the diagnosis of anaphylactoid reactions. Techniques include intradermal tests and prick-tests. The current localizations are the forearm and the back. Positivity criteria are 3 mm for prick-tests. For IDTs, the criterium is the doubling of the size of the injection papula, when 0.02 to 0.04 ml is injected : 8 mm. The recommended concentrations are not falsely negative. Commercial concentrations can be tested by prick tests, except for mivacurium and atracurium tested at 1:10 dilution. A scale of concentrations is advised for IDT starting with 1:10 000, up to normally non reactive concentration that is : 100 μg/ml (succinylcholine), 200 μg/ml (gallamine), 10 μg/ml (atracurium), 2 μg/ml (mivacurium), 200 μg/ml (pancuronium), 400 μg/ml (vecuronium), 1 000 μg/ml (rocuronium), 200 μg/ml (cis atracurium). The specificity and sensitivity of the skin tests to MRs are greater than 95%. The reproducibility over years is 88%. The overall concordance of PT and IDR is 97%. Both types of tests can be used for the diagnosis. IDT have to be carried out for the search of the cross sensitization. 84% of patients do have cross sensitization to MRs but only 16% react to all MRs. The further use of MRs selected by negative IDTs has been proved to be safe.
Revue / Journal Title
Allergie et immunologie
Sincerely,
Phil Lieberman, M.D.
7205 Wolf River Boulevard, Suite 200
Germantown, TN 38138
Telephone: 901-757-6100
Fax: 901-757-6109
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