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Updated guidance on perioperative allergic reaction evaluation and subsequent anesthesia

Published Online; May 2021

Given that multiple drugs are administered simultaneously, identification of the causative agent(s) after a perioperative allergic reaction is challenging. Allergy practice guidelines recommend comprehensive skin testing using the non-irritating concentration to all perioperative agents given prior to the allergic reaction. However, despite this recommended thorough evaluation, US data show that a causative agent is not commonly identified, making subsequent procedures with anesthesia challenging.

In this issue of The Journal of Allergy and Clinical Immunology: In Practice, Banerji et al., performed a retrospective review of all patients referred to their outpatient Allergy/Immunology clinic for perioperative allergic reactions between October 2003 and May 2017. Patient demographics, atopic history and prior adverse drug reactions were reviewed.  Patients underwent a comprehensive evaluation including skin testing using non-irritating skin test concentrations, drug challenges (when appropriate), tryptase level measurement, and specific IgE to latex measurement. Follow-up information on procedures requiring subsequent anesthesia were collected by structured telephone interview and electronic health record review.  

There were 123 patients with perioperative allergic reactions tested, and at least 1 causative agent was identified for 24% of patients. Among skin test positive patients, antibiotics (especially cefazolin), were the most common culprits. The majority (91%) of patients safely received subsequent anesthesia following the described comprehensive Allergy/Immunology evaluation for perioperative allergic reactions. An elevated baseline tryptase level was associated with an increased risk of recurrent perioperative allergic reactions. Despite broad testing, Allergy/Immunology evaluation can often be unrevealing but considering a broader range of potential causative agents may improve diagnosis; Banerji et al., describe important ways to expand and improve clinical care for this important patient group in the United States.

The Journal of Allergy and Clinical Immunology: In Practice is an official journal of the AAAAI, focusing on practical information for the practicing clinician.

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