Sei sulla pagina 1di 50

ANAPHYLAXIS IN ANESTHESIA

HISTORY
The term anaphylaxis was coined by PORTER AND RICHET 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 among commercial products and drugs .

GELL AND COOMBS CLASIFICATION


ANAPHYLAXIS is a TYPE 1 reaction IgE mediated

hypersenstivity 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 a

direct 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 prevalence

of 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 and onset 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 or recovery room Colloid may cause immediate reaction or delay onset

4.Previous allergies from drugs or 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 or M.A.C. Respiratory sym. rhinitis ,laryngeal edema,shortness of breath,wheezing,respiratory arrest

i
Increased peak inspiratory pressure, increased end

tidal carbon dioxide ,decreased oxygen saturation,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 to

mast 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 as histamine,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. NRL12.1% 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 agentMiscellaneous -aprotinin,chymopapain,protamine,

TREATMENT
DISCONTINUATIN OF DRUG OR ANESTHETIC

100% OXYGEN AIRWAY SUPPORT to incrase

oxygen delivery and maintain airway IV FLUIDS (2-4litres) for compensation of systemic vasodilation. EPINEPHRINE is drug of choice because its alpha 1 effects support the blood pressure and beta 2 effects provide bronchial smooth muscle relaxation 5-10micrograms initial bolus upto 100-500mic. For vascular collapse , start drip with 1 mic./min. for refractory hypotension

CONTINUED.
H1 blockers diphenhydramine 25-50 mg should be

used early but their role is controversial once cardiac sym. 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 and prevent 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 flexible molecule that crossreacts link 2 mast cell IgE receptors and induce mast cell degranulation 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 person

Cross 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 previous

history to reation in future anesthesia whenever possible

LOCAL ANASTHETICS
vasovagal responses ,tachycardia,lighthededness or

Metallic taste , perioral numbness can result from intravascular injection of local anesthetic or epinephrine Anaphylaxis is very rare, type 4 reaction is most common 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 catheterization

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

Potrebbero piacerti anche