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Anaphylaxis. Dr. S. Parthasarathy MD., DA., DNB( anaes ), MD ( Acu ), Dip. Diab . DCA, Dip. Software statistics PhD ( physio ) Mahatma Gandhi medical college and research institute , puducherry – India . Definition .

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anaphylaxis

Anaphylaxis

Dr. S. Parthasarathy

MD., DA., DNB(anaes), MD (Acu),

Dip. Diab. DCA, Dip. Software statistics

PhD (physio)

Mahatma Gandhi medical college and research institute , puducherry – India

definition
Definition
  • Anaphylaxis is an acute reaction leading to severe physiologic derangements of multiple systems.
  • Follows the administration of allergen to a sensitized individual
  • True anaphylaxis denotes an IgE antibody-

mediated reaction

  • Non IgE antibody- mediated reaction resembling anaphylaxis is anaphylactoid reaction
why should there be a name like that
Why should there be a name like that ??
  • Inj TT – protects further tetanus disease
  • This is prophylaxis
  • Portierand Richet in 1902 reported that the second injection of sea anemone extract into

dogs resulted in a fatal systemic reaction

  • Iron inj. -- First time – ok – on second injection It is fatal = antagonistic of prophylaxis – anaphylaxis
histamine release but not anaphylaxis
Histamine release but not anaphylaxis
  • Morphine
  • Skin alone ??
  • Atracurium
  • Skin and lungs also ??
why are some of us destined for a life of allergy and others not
Why are some of us destined for a lifeof allergy and others not?
  • Low grade responders
  • Ige antibodies less with interferons
  • High grade responders
  • Ige antibodies more with cytokines
incidence in anaesthesia
Incidence in anaesthesia
  • It varies
  • 2 in 10,000 to 4.5 in 10000
  • In france single institution study – 16 in 10000
clinical manifestations of anaphylaxis
Clinical manifestationsof anaphylaxis
  • IV antigen ----= starts in 5 minutes
  • Other routes like oral
  • Slower and less rapid progression
clinical tips may not be severe
Clinical tips – may not be severe
  • Already asthmatic -
  • Already on beta blockers
  • Ill health
grades of clinical signs
Grades of clinical signs
  • Grade I presence of cutaneous signs; (10%)
  • Grade II as presence of measurable but not life-threatening symptoms including cutaneous effects, arterial hypotension(22%)
  • Grade III as presence of a life-threatening reaction, collapse , severe bronchospasm, arrhythmias ,(66 %)
  • Grade IV cardiac and/or respiratory arrest (4%)
anaesthesia
Anaesthesia
  • symptoms -- Cutaneous, respiratory, CVS, GI
  • Single system involvement – overlooked
  • During general and regional anesthesia or

during deep sedation, cardiovascular signs predominate

Epidural hypotension –give colloids – anaphylaxis to colloids --- Gloom ??

anaphylaxis under anaesthesia is not routine most common triggers
Anaphylaxis under anaesthesiais not routine — most common triggers
  • It is not community anaphylaxis like –
  • Food stuff
  • Bee sting
  • Wasps
  • Snake bites
  • What happens in anaesthesia ??
  • Unconscious !!
anaesthesia confounding
Anaesthesia – confounding
  • During general anaesthesia, early symptoms of anaphylaxis such as tongue swelling, itch, breathing difficulty and wheeze
  • Skin lesions under the drapes
differential diagnosis
Differential diagnosis
  • In a conscious patient, anaphylaxis is most easily confused with a vasovagal reaction, which may occur when a patient collapses after an injection or painful procedure
  • But there is a bradycardiain a vasovagal reaction
differential diagnosis1
Differential diagnosis
  • cold urticaria (especially if generalized), idiopathic urticaria, carcinoid tumors, and systemic mastocytosis.
  • Symptom based DD
who are prone
Who are prone ??
  • Females
  • Previous anaphylaxis
  • patients with spina bifida or allergy to some fruit- latex allergy
  • IgA deficiency- blood and colloids
treatment of anaphylaxis
TREATMENT OF ANAPHYLAXIS
  • Initial
  • Secondary
initial
Initial
  • Remove the offender
  • Venous tourniquet
  • Airway maintenance with 100% oxygen
  • laryngeal edema -- aerosolized epinephrine

epinephrine by nebulizer (8–15 drops of 2.25% epinephrine in 2 mL normal saline)

  • Large bore IV lines
  • intravascular volume should be maintained with administration of isotonic crystalloid
slide20

Rapid infusion of an initial bolus of 1–2 L

intravenous fluid initially (20 mL/kg initially in children) before reassessment.

  • Adults may require 2–5 L.
severe hypotension or airway obstruction
severe hypotension or airway obstruction
  • 0.1-mL (100μ g of a 1:1000 dilution) increments of epinephrine should be given intravenously, usually not exceeding 0.5 mg total.
  • Beware – halothane, stroke, infarction
no iv access
NO IV access
  • 0.3 mL of 1:1000 epinephrine can be given subcutaneously or intramuscularly, or 10 mL of 1:10,000 epinephrine can be administered through the endotracheal tube.
  • Hypotension and bronchospasm
  • Norad, dopamine infusions to follow
secondary
Secondary
  • Antihistaminics – diphenhydramine
  • Ranitidine 1 mg/ kg
  • Steroids : hydrocortisone- 5 mg/kg (up to 200 mg initial dose) and then 2.5 mg/kg every

6 hours- methylprednisolone 1 mg/ kg initially and every 6 hours

IV aminophylline infusion

  • Bicarbonate – controversial
refractory hypotension
Refractory hypotension
  • Glucagon may be administered as a 1–5 mg (20–30 μg/kg in children, maximum 1 mg)

dose over 5 min followed by an infusion of 5–15 μg/ min

Recently – vasopressin

diagnosis
Diagnosis
  • Mast cell tryptase
  • Postmortem collection of samples for assay is also possible
  • 2 tubes 5 – 10 ml – 6 hours gap within 48 hours means 4 deg
  • Or – 20 deg.
diagnosis1
Diagnosis
  • Immunodiagnostic Tests
  • Intradermal skin tests still are the most readily available and generally useful diagnostic tests

for drug allergy.

Total Serum IgE Levels

  • Assays to Measure Complement Activation
  • Blood and urine assay of histamine mediators
  • Radioallergosorbent Testing
neuromuscular blocking agents
NeuromuscularBlocking Agents
  • Suxamethonium
  • Pancuronium, atracurium, alcuronium
opioids
Opioids
  • Histamine release is common Morphine and pethidine
  • anaphylaxis are rare
  • NSAIDs
  • Penicillin and betalactams, cephalosporins, septran
  • Skin test is almost foolproof to avoid it.
radiocontrast
Radiocontrast
  • Urticaria, angioedema, wheezing, dyspnea, hypotension, or death occurs in 2–3% of

patients receiving intravenous or intraarterial

infusions.

Oral prednisolone, with AH prior to IV contrast

local anaesthetics
Local anaesthetics
  • Genuine allergic reactions to local anaesthetic agents are extremely rare
  • Preservatives
colloids
Colloids
  • Clinical anaphylaxis to all groups of colloids is possible, including gelatins (such as Haemaccel® and Gelofusine®), albumin, dextrans and starches.
  • Dextrans proved
methylmethacrylate
Methylmethacrylate
  • Episodes of hypotension , tachycardia reported
  • Whether anaphylaxis – proved ??
  • Protamine
  • Diabetics – use insulin protamine
induction agents
Induction agents
  • Propofol was originally formulated in a vehicle

containing Cremophor® EL but was reformulated as a lipid emulsion following reports of severe allergic reactions.

Egg allergy ??

Thiopentone reported , methohexital – no

transfusion related anaphylaxis
Transfusion-RelatedAnaphylaxis

In GA

  • Refractory unexplained hypotension
  • Haematuria
natural rubber latex
Natural Rubber Latex
  • Children with spina bifida and urogenital anomalies
  • Gloves
  • Ambu bag
  • Reservoir bags
  • Masks
  • Latex injection ports
  • Tourniquets
  • Blood pressure cuffs
summary
Summary
  • Definition ,mechanism , incidence
  • Clinical manifestations
  • Differential diagnosis
  • Lab
  • Treatment
  • Anaesthetic factors and tips