xis in anesthesia

8/4/2019 xis in Anesthesia

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ANAPHYLAXIS IN

ANESTHESIA



HISTORY

The term anaphylaxis was coined by PORTER ANDRICHET in 1902

In greek prophylaxis means “protection”,

ANAPHYLAXIS means opposite protection Anaphylaxis generally occurs on re-exposure to a

specific antigen and requires the release of proinflammatory mediators but it can also occur on

first exposure because of cross reactivity amongcommercial products and drugs .



GELL AND COOMB’S CLASIFICATION

ANAPHYLAXIS is a TYPE 1 reaction IgE mediatedhypersenstivity reaction

TYPE 2 reactions involve IgG Ig M and complement

mediated cytotoxicity TYPE 3 REACTIONS involve immune complex

formation and deposition leads to tissue damage

TYPE 4 reactions are delayed type hypersenstivity

reactions



ANAPHYLACTOID REACTIONS

ANAPHYLACTOID REACTIONS occur through adirect nonimmune mediated reaction via release of mediators from mast cells and basophils but they present with symptoms similar to those of anaphylaxis



SCOPE

Prevalence and incidence

Cause of perioperative anaphylaxis

Diagnosis

Management



PREVALENCE

IT IS Difficult to determine incidence and prevalenceof anaphy.

Acc. To an estimate it is 1 in 3500 to 1 in 13000

Mortality 3-6 % Multiple drugs are administered during anesthesia

And because patients are under drapes early cutaneous symptoms are often unrecognized

no available diagnostic test with absolute accuracy

NMBA usually result skin test +ve for long time



CLINICAL HISTORY

1.Extent of sign of anaphylaxis

2. Drugs and related compounds

3. Time elapsed between administration and

onset of symptom 4. Previous allergies from drugs or related

compounds

5. underlying conditions



EXTENT OF SIGNS OF ANAPHYLAXIS

In most cases

perioperative anaphylaxis is

characterized by cardiovascular

manifestation (73.6%),cutaneous symptoms(69.6%),and bronchospasm (44.2%) of cases.



Time elapsed between administration andonset of symptom

Clinical sign usually start within 5-10 min after IV

administration but may occur in second

NRL and antiseptics exhibit more delay onset and

generally occur in maintenance anesthesia orrecovery room

Colloid may cause immediate reaction or delay onset



4.Previous allergies from drugsor related compound

Careful retrospective assessment of medical

history and record

Identify risk of patients during preanesthetic visit



5.Underlying conditions

identified underlying condition can also help

to identify causative compounds

Atopic individual are at the risk of anaphylaxis

from NRL Mastocytosis,



CLINICAL FEATURES

Cutaneous sym.

Flushing ,pruritus urticaria ,angioedema

G.it. Sym.

Nausea ,vomitting ,abdominal cramps ,diarrhoea Absent or difficult to differentiate in general

anesthesia , may be present in regional anesthesia orM.A.C.

Respiratory sym. rhinitis ,laryngeal edema,shortness of

breath,wheezing,respiratory arrest



i

Increased peak inspiratory pressure, increased endtidal carbon dioxide ,decreased oxygensaturation,wheezing,bronchospasm

CARDIOVASCULAR SYM.

Tachycardia ,hypotension,cardiac arrythmias ,cardiovascular collapse

RENAL SYM.

Decreased Urine output HEMATOLOGIC SYM.

D.I.C.



PATHOPHYSIOLOGY

On initial exposure IgE is produced and binds tomast cells and basophils

On reexposore multimeric antigen cross links two

IgE receptors initiating a signal transduction cascade Which culminates in increase of calcium and release

of mediators such ashistamine,proteases,proteoglycans,and P.A.F.



TRYPTASE

Neutral serine proteinase

Mature -tryptase reflect mast cell activation

Pro -tryptase reflect mast cell number

Mast cell or basophil 60-120 min collection after event

Compare 2 sample in the same person

Persistent elevate in….. False – ve & false



ETIOLOGY

NMBAs – 69.2% succinyl choline ,rocuronium,atra.

NRL- 12.1% latex gloves

Antibiotics-8% penicillin,and beta lactams

Colloid- 3.7% dextran,gelatin Hypnotics-2.7% propofol,thiopentone

Opioids- 1.4% morphine ,meperidine

Local anesthetic agent- Miscellaneous -aprotinin,chymopapain,protamine,



TREATMENT

DISCONTINUATIN OF DRUG OR ANESTHETIC

100% OXYGEN AIRWAY SUPPORT to incraseoxygen delivery and maintain airway

IV FLUIDS (2-4litres) for compensation of systemic vasodilation.

EPINEPHRINE is drug of choice because its alpha 1effects support the blood pressure and beta 2 effectsprovide bronchial smooth muscle relaxation

5-10micrograms initial bolus upto 100-500mic. For vascular collapse , start drip with 1 mic./min. forrefractory hypotension



CONTINUED….

H1 blockers diphenhydramine 25-50 mg should beused early but their role is controversial once cardiacsym. Set in

H2 blockers ranitidine 150 ms bolus or cim etdine

400mg bolus should be added Bronchodilators eg.albuterol and ipratropium

bromide nebulizers

Corticosteroids decrease airway swelling andprevent recurrence of sym.as seen in protracted and

biphasic ana.hydrocortisone is preferred steroid because of fast onset



CONTINUED……..

Extubation should be delayed .because airway swelling and inflamation may continue for 24 hours. Patient should be managed in I.C.U.



PREVENTION



MUSCLE RELAXANTS

NMBAs are most common cause of anaphylaxis Short acting depolarizing is at greatest risk

succinylcholine because it contains a flexiblemolecule that crossreacts link 2 mast cell IgEreceptors and induce mast celldegranulation

N.M.B. Induce 2 type of reactions

- IgE dependent => NH4+ main antigenic epitope - direct mast cell activation => benzylisoquinolinium

cisatracurium has lowest risk of mast cell activation



Data controversy in rocuronium

Cross reactivity between NMBAs is 65% by skin test

and 80% by RIA

Pattern of cross reactivity vary between personCross reactivity depend on configuration,

flexibility,inter-ammonium distant

Unusual to allergic to all NMBAs But keep in mind some pt. might suffer from

multiple allergies



PREVENTION

Avoid NMBAs for patient with previoushistory to reation in future

anesthesia whenever possible



LOCAL ANASTHETICS

vasovagal responses ,tachycardia,lighthededness orMetallic taste , perioral numbness can result fromintravascular injection of local anesthetic orepinephrine

Anaphylaxis is very rare, type 4 reaction is mostcommon

Amide-rare , ester< 1% for anaphylaxis

Ester metabolite=> PABA usually cause

type I reaction

Preservative => methylparaben



HYPNOTICS

Cross reactivity between thiopental sodium

barbitone,methohexital( rare anaphylaxis)

Propofol => alkyl phenol that bear 2 isopropyl

groups that act as antigenic epitopes - cross react with eggs ,soy and lechitins in

propofol vehicle ?

upto now no evidence support this postulate



OPOIDS

generalized reaction to opioids usually result

from nonspecific mast cell activation

Skin mast cell are sensitive to nonspecific

activation , in contrast to heart,GI,lung How about basophil?

Classification of opioid

- phenanthrene (morphine,codeine) - phenylpiperedine(phentanyl,meperidine)

- diphenylheptane(methadone,propoxyphene



Most of reaction are not life-treatening reaction

Fentanyl appear not to activate mast cell

Data in cross reactivity of opioid subclass is

inconclusive SPT for opioids is not useful Placebo controlled

challenges may be required to

diagnose opioid allergy



NATURAL RUBBER

Divided into 2 groups

- atopic

- significant exposure=>HCP, Neural tube

defect 20% of perioperative anaphylaxis

Use questionaire

Rx => avoidance



% of perioperative anaphylaxis

20% severe reaction

20 min after administration

Gelatin allergy - Skin test (phadiac 74,BAT

HES

- skin test



rextran => DIAR

- IgG immune complex dis

- prevent by hapten dextran (1Kd) infusion

- skin test is not established Albumin anaphylaxis is anectodal case



Chlorhexidine and other antiseptics

Cationic biguanide

Chlorhexidine salt can trigger irritant

dermatitis

SPT 10 fold dilution of chlorhexidine digluconate in 70% alcohol

sIgE (c8,Phadia)

Povidone iodine => anaphylaxis is rare



OTHER AGENTS

Hyaluronidase

Oxytocin

dyes

Aprotinin Protamine and heparin



PROTAMINE

Isolate from the sperm of fish

Antidote for heparin

Significant histamine release

Previous exposure (NPH),heparin neutralization, vasectomy,fish allergy may

risk for anaphylaxis

But these finding not confirm Skin test ,sIgE may be helpful



cardiac



cardiaccatheterization



conclusion

Prevance of peri-operative anaphylaxis

Diagnostic approach

NMBAs is MCM cause

Diagnostic test Anaphylaxis and anaphylactoid

Almost procedure and medication can cause

peri-operative anaphylaxis

xis in anesthesia

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