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Anaphlaxis
Dr Ferdi Menda
Anaphylaxis


A severe life threatening (Type I) immediate
hypersensitivity reaction.
The reaction occurs when the person
reexposed to an ‘allergen’, which leads to IgE
Ab during previous exposure.
Anaphylaxis
Injected,
inhaled or ingested substance
–usually drugs, food, insect venomcan serve as the allergen itself.
Anaphylaxis
• During 1st exposure,
mast cells (A)-allergen (B)
complex secrete IgE (C)
antibodies.
• Some of these IgE
remain attached to the
mast cells.
• During the 2nd exposure
allergen combines with IgE
on the surface of the cell &
release inflammatory
mediators.
Anaphylaxis

Allergen:

IgE + Ag


Mast cells, basophils:
Histamin, triptase, leukotriens, eosinophilic
chemotactic factors are released.
IgG leads to “complemant” system
activation.
Anaphylaxis

Non-Allergic (non-IgE, non-immun):

Reaction is developed by means of direct
pharmacologic, toxic stimulus of the mast cells
& basophils; Inflammatory mediators are
released.
Uniphasic Anaphylaxis
Treatment
Initial
Symptoms
0
Antigen Exposure
Time
Biphasic Anaphylaxis
Treatment
Treatment
1-8 hours
Second-Phase
Symptoms
Initial
Symptoms
Classic Model
0
1-72 hours
Antigen Exposure
New Evidence
Time
Protracted Anaphylaxis
Initial
Symptoms
0
Antigen
Exposure
Time
Possibly >24 hours
Anaphylactoid reaction

An identical or very similar clinical response
(skin reaction) which is not mediated by IgE,
or an Antigen-Antibody process.
Anaphylaxis during Anesthesia



Anaphylaxis incidence during anesthesia is:
1/5.000-1/20.000
Multiple drug use duing general anesthesia may
mask the symptoms.
Diagnosis during anesthesia is DIFFICULT !
Agents responsible for anaphylaxis during
Anesthesia





Non-depolarizing neuromuscular blockers
Latex & antibiotics
Colloid solutions, barbituric acid
All drugs & agents used during surgery or
anesthesia may be responsible
Mind the solutions or drugs used by the
SURGEON !!
Cerrahın kullandıklarına DİKKAT !!





Topical, infiltration Local Anesthetic agents
(<%1 anaphylaxis)
Irrigation solutions
Latex
Disinfectant
Markers (patent blue)
Mast cell
activation,
degranulation
Respiratory system
Airway
GIS
Increased peristaltism
Nausea, vomiting
Bronchospasm,
Upper airway
edema
CVS
Hypotension,
tachycardia, arrhytmia,
collaps
SKIN
Erythema
Urticaria
Edema
HYPOVOLEMIA;
Deep general anesthesia;
Deep regional anesthesia may mask the symptoms.
SKIN
Erythema
Urticaria
Edema
UPPER AIRWAY
• Stridor
• Hoarseness
• Angioedema
• Sneezing
Respiratory system
• Wheezing
• Dyspnea
Normal Airway
Airway inflammation
Bronchospasm &
mucus production
Cardiovascular symptoms
arrhythmias
Gastrointestinal symptoms



Nausea, vomiting,
Diarrhea,
Abdominal cramp like
pain: uncommon except
with food allergies.
Anaphylaxis:

Generally occurs immediately after drug
injection (2-15 mins).
Generally related to iv agents.
Rarely occurs 2.5 hour after the drug therapy.
No death reports > 6 hours after the reaction.

Reaction time following oral drug intake is



unpredictable
?
Anaphylaxis therapy*






STOP the responsible agent
Call for HELP
Warn the SURGEON
Trandelenburg position
Ventilation+%100 O2
Fluid therapy:
500-1000 mL iv adult, ≥20 mL/kg çocuk
(%09 NaCl, RL)
* Kroigaard M. Scandinavian Clinical Practice Guidelines on the diagnosis, management
and follow-up o anaphylaxis during anaeshesia. Acta Anaesthesiol Scand 2007 + ERC
2010.
Anaphylaxis therapy: ADRENALIN*
PEDIATRIC
ADULT:

Severe anaphylaxis



0.1-1 mg
0.5-0.8 mg

iv
im
Mild rxn: 10-50 micg iv
Severe anaphylaxis



0.01 mg/kg iv
5-10 micg/kg im
Mild rxn: 1-5 micg/kg iv
* Kroigaard M. Scandinavian Clinical Practice Guidelines on the diagnosis, management
and follow-up o anaphylaxis during anaeshesia. Acta Anaesthesiol Scand 2007.
Anaphylaxis therapy: ADRENALIN*
>12 y/o & adult
0.5 mg IM
6–12 y/o
0.3 mg IM
<6 mo–6 y/o
0.15 mg IM
IV ADRENALIN:
ADULT:
50 micg titrate,
PEDIATRIC: 1 micg/kg.
* ERC anaphylaxis guidelines 2010.
Epinephrine Injection: IM vs. SQ
Simons et al:Prospective, randomized, blinded study in children T-max was 8 ± 2
minutes after injection of epinephrine 0.3 mg from an EpiPen IM in the vastus
lateralis vs. 34±14 minutes (range, 5 to 120) after injection of epinephrine 0.01
mg/kg SQ in the deltoid region.
Epinephrine Absorption: SQ vs. IM
Simons FER et al. J Allergy Clin Immunol 1998;101:33-7.
Anaphylaxis: Segondary therapy ?
CORTICOSTEROID
Adult


HIDROCORTISON 250 mg,

M.Prednisolon 80 mg iv
Pediatric

HIDROCORTISON 50-100 mg,

M.Prednisolon 2 mg/kg iv
Antihistaminic:
Adult


Promethazin 50 mg iv
Pediatric

Promethazin 0.3-1 mg/kg
iv/im
Bronchospasm: nebulised β2-agonist. Not a 1st choice therapy.
Anaphylaxis: Unresponsive to Adrenaline !

NORADRENALIN: 0.05-0.1 mcg/kg/min
VASOPRESSIN : 2-10 IU iv doses until response.

GLUCAGON

: 1-2 mg iv doses until response (in
patients taking beta-blocker & unresponsive to high dose adrenaline).
Patients having anaphylactic rxn previously with


Polen, animal fur, dust atopy
Former prolonged latex exposure
may develop reaction with LATEX.
RECOMMENDATIONS



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Anaphylaxis with Local Anesthetics is RARE; prefer
Regional or local anesthesia.
Agent of choice for General anesthesia is
VOLATILE. “No Anaphylaxis is reported”
AVOID Latex & Neuromusculer blockers !
Antihistaminic/steroid premedication will probably
not prevent “anaphylactic shock” ?
If known to cause a previous reaction, avoid using
that drug/agent.
Follow-up

After a moderate-severe anaphylactic rxn:




Follow-up with blood (triptase), then skin test.
Skin test: skin prick, intradermal test (IgE) or
If there is a local or disseminated urticeria related to
Chlorhexidin skin test is necessary.
Follow-up is not necessary:

Erhythema around the injection site, isolated
bronchospasm in patients with previous bronchial
reactivity.
When we decide an Alergy test, the following
should be reported:







Symptoms
Severity of the reaction
Onset time and length of the reaction,
Therapy
All the agents used before the reaction
Anesthesia form, notes
Fill the advers event form.
Primary evaluation

Serum triptase & IgE Ab.
Blood sample for analysis must be drawn within 1-4 hrs
following the rxn. 5-10 mL blood, serum. The timing of the
blood sampling after the reaction should be noted ?


Control blood sample should be drawn before
Anaphylaxis or 24 hrs after the reaction.
Blood for IgE analysis can be sampled within 6 months
after the reaction.
Secondary evaluation
Skin test:
Evaluates mast cell rxn by IgE. Salin (-) control, Histamin (+)
control. Test has to be done 6 weeks after the reaction.


Bir NMBA ile (+) sonuç alındıysa, diğer NMB test edilmeli.

Bir LA rxn varsa diğerleri test edilmeli. Cross reactivity.
Drug provacation test: RISKY !
 It has to be performed after the skin test.
Generally 1/10 of the therapeutic dose of the drug responsible for
the reaction is given via same route.
Frequently used agents during Anesthesia





NMBA. (skin prick test “gold standart”)
 1/5.000-10.000 (france,norway,GB).
 Other countries 1/50.000-1/150.000.
Latex (<5-17.7%)
Antibiotics. (Penicillin 0.1%)
 15% of all the Anaphylactic rxns
Chlorhexidin.
 12% of all the rxns during anesthesia are related to
it (in denmark).
Gelatin (4%-france). HES (0.006%)
Frequently used drugs during Anesthesia




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Ketamine, Midazolam. Very rare.
Opioids.
Low incidance.
L.Anesthetics.
Very low.
Propofol. (2.3%)
Rare.
Thiopental.
1/23.000-29.000
(higher in female)
NSAID. (general population 1%) rarely a problem during
anesthesia. COX-2 inhibitors may be safer ?
WARN the patient


Bracelet
Detailed epicrisis