Skin changes allow early recognition of perioperative IgE-mediated anaphylaxis
Published: February 17, 2024
Perioperative anaphylaxis, a life-threatening, usually IgE-mediated, immediate hypersensitivity characterized by acute circulatory failure, is still a significant cause of anesthesia-related deaths. Anaphylaxis usually occurs around anesthetic induction, with neuromuscular blocking agents and β-lactam antibiotics being primarily involved. However, bedside diagnosis is not always straightforward because the presentation may vary. Information on early anaphylaxis characteristics would facilitate diagnosis and treatment decisions.
In a recent article published in The Journal of Allergy and Clinical Immunology: In Practice, Dewachter et al. investigated the clinical and paraclinical characteristics of patients with perioperative immediate hypersensitivity (POH). The authors conducted a retrospective study of consecutive adult patients with suspected POH who were referred to two Parisian academic allergy-anesthesia units during a five-year period (2013-2018). This is the first study to investigate the association of early characteristics, focused on cutaneous signs, with IgE-mediated allergy in the perioperative setting. Specifically, this study sought to determine whether inaugural skin changes would help recognition of IgE-mediated anaphylaxis. Eligible patients were investigated according to current guidelines. Acute plasma histamine and total tryptase levels, as well as skin test results, were related to the clinical history, including time frame between drug exposure and clinical presentation. Severity was assessed using the modified Ring and Messmer scale.
Of 145 patients enrolled, the median age was 55 years, 76 (52.4%) were women, and 99 (68.3%) and 46 (31.7%) were respectively categorized in the IgE-mediated allergy and non-allergy groups. Cutaneous vasoconstriction phenotype (pallor and/or piloerection and/or thelerethism and/or sweating with or without cyanosis) occurring within minutes, or even one minute, of drug exposure was the strongest factor associated with IgE-mediated allergy. Early cutaneous vasoconstriction manifested exclusively in life-threatening allergy, may therefore be regarded as pathognomonic of IgE-mediated anaphylaxis. Other early factors were low end-tidal carbon dioxide ≤ 25 mm Hg (as a surrogate of cardiac output), low mean arterial pressure ≤ 60 mm Hg, and early cutaneous vasodilation (localized/generalized erythema with or without palpebral/labial angioedema or extensive urticaria). Late cutaneous vasodilation (localized/generalized erythema or extensive urticaria) occurring after restoration of hemodynamics corroborated the diagnosis of allergy. This study provides an updated approach to the clinical spectrum of IgE-mediated anaphylaxis, for which skin assessment enables quick recognition. These findings also suggest that the skin could reflect systemic hemodynamics and might be used as a tool to guide resuscitation in POH focusing on individual characteristics.
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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