Allergic Reactions to Anaesthetic Drugs[1]

8/12/2019 Allergic Reactions to Anaesthetic Drugs[1]

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ALLERGIC REACTIONS TO

ANAESTHETIC DRUGS

Philippe SCHERPEREEL

Professor Emeritus of AnaesthesioloCentre Hospitalier Rgional Universit59037 LILLE FRAN

[email protected] MURES 2009


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ALLERGIC RISK IN ANESTHESIA

IS SUBJECT TO CONTROVERSY BUT SEEMS RELATIVELY

FREQUENT: 9 19 % OF THE ACCIDENTS LINKED TO

ANESTHESIA REPRESENTING IN FRANCE (2002)

1/22,500 Anesthesia

1/6,500 anesthesia implicating a myorelaxant

SEVERE: 5 17 % OF DEATHS


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DEFINITIONS

ALLERGIC REACTION (HYPERSENSITIVITY)

Immune pathological reaction

In an individual previously sensitized

Linked to the production of

Specific antibodies (IgE: humoral immunity)

Sensitized cells (T lymphocytes: cell immunity)

ANAPHYLACTIC REACTION (Anaphylaxy)

Immune specific response

Induced by IgE antibodies (immediate hypersensitivity)

Producing a mast cell and basophiles degranulation

ANAPHYLACTOID REACTION (non specific histamine release)

Pharmacological effect on mast cells and basophiles

Histamine release proportional to the speed of injection andthe drug concentration

Not an immune reaction


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FIRST SENZITIZINGCONTACT

BASOPHILEMAST CELLTRYPTASE

Production ofIgE antibodies

HISTAMINE

ANAPHYLACTIC REACTION MECHANISM


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SECOND FIRINGCONTACT

RECEPTORS H1 H2

Dgranulationof mast cells

IgE


Specific histaminrelease

TRYPTASE

HISTAMINE


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FIRST CONTACT

RECEPTEURS H1 H


TRYPTASE

HISTAMINE

Dgranulationof mast cells

Non specifichistamine releas


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THE COMPLEMENT PATHWAY

CLASSICAL PATHWAY

LYTIC PATHWAY

ALTERNATIVE PATHWA

ProperdinFactors D et B

C3 aanaphylatoxin

C5 a

anaphylatoxin

C5 b 6789Membrane Attack Complex

C 3

C 5

C 1

C3 bOpsonin

C2

C4

BJA 1995;74:217

C 3 (H2O)


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CLINICAL SYMPTOMS

STAGES OF INCREASING SEVERITY

1. GENERALIZED SKIN AND MUCOUS SYMPTOMS Rasch, urticaria with or without angioneurotic edema

2. MILD MULTIVISCERAL ATTACK Skin and mucous symptoms

Hypotension, tachycardia

Bronchial hyper reactivity : cough, dyspnea3. SEVERE MULTIVISCERAL, ATTACK LIFE THREATENING

Collapse, tachy or bradycardia, dysrthymias

Bronchspasm

Skin symptoms sometimes missing appearing after tensionrecovery

4. CIRCULATORY INEFFICIENCY, CARDIAC ARREST

5. DEATH BY CPR FAILURE


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CLINICAL SYMPTOMS OF ANAPHYLAXY DURING ANESTHESIAACCORDING TO THE MECHANISM

from PM Mertes et al. Ann Fr Anesth Reanim 2004;23:1133-43

Clinical symptoms Anaphylactic

reaction (n=491)

Anaphylactoid

reaction (n=221)

Skin symptoms

- Rash

- Urticaria

- Angioneurotic edema

326 (66,4 %)

209 (42.6 %)

101

50

206 (93.6 %)*

151 (68.3 %)

54 (24.5 %)

16 (7.2 %)Cardiovascular symptoms

- Hypotension

- Collapse

- Cardiac arrest

386 (78.6 %)

127 (25.9 %)

249 (50.7 %)

29 (5.9 %)

70 (31.7 %)*

50 (22.6 %)

12 (5.4 %)

0

- Bronchospasm 196 (39.9 %) 43 (19.5 %)

* P


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GRADES OF SEVERITY OF REACTIONS DURING ANAESTHESIAACCORDING TO THE MECHANISM

from PM Mertes et al. Ann Fr Anesth Reanim 2004;23:1133-43

0

10

20

Anaphylactic (n=491)Anaphylactoid (n=221)

30

I II III IV

40

50

60

V

GRADES OF SEVERITY

%


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COMPLEMENTARY INVESTIGATIONS

IMMEDIATE: during and immediately after the accident

Histamine (blood)

Tryptase

IgE specific antibodies

DELAYED: 6 weeks after the accident

Skin tests

Prick tests

Intra dermal reactions (IDR)*

Biological dosages

Histamine release from leucocytes Specific allergens detection (RAST)

Basophil Activation Test (BAT) with triple labelling


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PLASMA TRYPTASE MEASUREMENT

2

8

14

20

26

1 2 4 8 16 32 64Hours after reaction

Tryptaseconcentration

(u.l

iter-1)

According to MATSON et P et al. 1991;33:211-1

- Enzyme. Exclusively stored in mast cells

. In favour of anaphylactic reaction

. Blood peak (>25 g/l): 30 min-2 h

. Half life time in plama = 90 min


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ANAPHYLAXY DURING ANAESTHESIA

Casal agent % 1989*

5n=821)

1992*

(n=813)

1994*

(n=1030)

1996*

(n=734)

1998**

(n=571)

2002*

(n=71

Myorelaxants 81.0 70.2 59.2 61.6 69.1 54.0

Latex 0.5 12.5 19.0 16.6 12.1 22.3

Hypnotics 11.0 5.6 8.0 5.1 3.7 0.8

Opiods 3.0 1.7 3.5 2.7 1.4 2.4

Colloids 0.5 4.6 5.0 3.1 2.7 2.8

Antibiotics 2.0 2.6 3.1 8.3 8.1 14.7

Miscellaneous 2.0 2.8 2.2 2.6 2.9 3.0

*Ann Fr Anesth Reanim **Br J Anaesth 2001 *** Ann Fr Anaesth Reanim 2004

CAUSAL AGENTS INVOLVED IN ANAPHYLACTIC REACTIONS DURING


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Autres

3%

Hypnosdatifs

0,8% (n=4)

Latex

22,3% (n=112)

Curares

54% (n=271)

Antibiotiques14,7% (n=74)

Collodes

2,8% (n=14)

Morphiniques

2,4% (n=12)

CAUSAL AGENTS INVOLVED IN ANAPHYLACTIC REACTIONS DURING

ANAESTHESIA IN FRANCE IN 2001 - 2002daprs PM MERTES Ann Fr Anesth Reanim 2004;23:1133-43

MYORELAXANTS INVOLVED IN ANAPHYLACTIC REACTIONS DURING


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MYORELAXANTS INVOLVED IN ANAPHYLACTIC REACTIONS DURING

ANAESTHESIA IN FRANCE IN 2001 - 2002according to PM MERTES Ann Fr Anesth Reanim 2004;23:1133-43

Atracurium

23,7% (n=64)

Cisatracurium

1,8% (n=5)

Rocuronium

26,2% (n=71)

Pancuronium2,6% (n=7)

Mivacurium

1,1% (n=3)

Suxamethonium

37,6% (n=102)

Vcuronium

7% (n=19)


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COMPARISON BETWEEN THE PERCENTAGE OF EXPOSED PATIENTS AN

ANAPHYLACTIC REACTIONS TO THE MYORELAXANTS IN 2001 2002according to PM Mertes and al Ann Fr Anesth reanim 2004;23:1133-43

* Data obtained from GERS Hospitals and Hospital Panel - MAP 1

EXPOSED PATIENTS*(n = 5.721. 172) % ANAPHYLACTICREACTIONS (n=271)

ATRACURIUM 60,3 23,7

CISATRACURIUM 14,7 1,8

SUCCINYL CHOLINE 8,2 37,6

ROCURONIUM 6,5 26,2

VECURONIUM 4,9 7,0

PANCURONIUM 1,9 2,6

MIVACURIUM 3,5 1,1

100 % 100 %

ANAPHYLAXY TO LATEX DURING ANAESTHESIA


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22,3 % OF ANAPHYLACTIC REACTIONS DURINGANAESTHESIA

72.9 FEMALES / 27.1 MALES COMPARED TO ANAPHYLAXY DUE TO MYORELAXANTS

Younger patients

Less severe reactions

PATIENTS WITH HIGH RISK OF LATEX ALLERGY

1. History of latex allergy- unexplained shock during a previous anaesthesia

- pruitus, rash, edema after contact with latex(gloves, condoms, balloons)

2. Repeated exposures to Latex- Health care providers

- Urologic malformations (spina bifida : 40%)

- multiple surgical interventions +atopy

3. Food allergy- bananas, avocados, kiwis, exotic fruits

PREVALENCE


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HISTORY OR ALLERGY IN PATIENTS WITH ANAPHYLACTIC REACTIO

TO LATEX AND MYORELAXANTS, IN FRANCE IN 2001 - 2002according to PM MERTES Ann Fr Anesth Reanim 2004;23:1133-43

MYORELAXANTS(n=271) %

LATEX(n=112) % p

ATOPY 10,3 26,0


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EQUIPMENTS FOR ANAESTHESIA AND SURGERY CANEXPOSE PATIENTS TO ANAPHYLACTIC REACTIONS BY :

DIRECT CONTACT WITH: Skin (facial mask, tourniquet)

Mucuous tubes, drains)

Organs (gloves, instruments)

Vessels (catheters)

INHALATION OF LATEX PARTICLES:

Anesthetic circuit: 1.5 to 2.8 of Latex natural proteins insuspension in the rubber

Air in the operating theater : adsorption of Latex naturalproteins on the starch powder of surgical gloves

MECHANISMS




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PATIENTS WITH HIGH RISK OF LATEX ALLERGY

SKIN TESTS: PRICK TEST- At the forearm

- With fresh latex extract standard

- Compared with a solution of codeine and a negative controlafter 15 minutes

- Prefered to IDR and scratch tests

DOSAGES OF LATEX SPECIFIC IgE

- Less the: rast tests (time consuming, expensive)

last (Latex allergo sorbent test not reliable: 18.8 %

- But the coated allergen particule test (CAP)positive for Latex specific IgE>0.35 kUI-1

- Reliable: 56.0 %

DIAGNOSTIC




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INFORMATION + + +

- In all the sites: O.R., recovery room, ward

- To all the people: surgeons, anesthetists nurses

- By all means: chart, bracelet, strap

LATEX FREE EQUIPMENT: LATEX FREE KITS- Gloves

- Circuits, ventilation devices

DRUGS AND MATERIAL TO TREAT AN ANAPHYLACTIC

SHOCK READY TO USESCHEDULED FIRST OF THE LIST

PROPHYLAXY


DECISIONAL TREE ALGORITHM


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DECISIONAL TREE ALGORITHM

EMERGENCY

SEARCH FOR ANESTHETIC PROTOCOL

CONSULTATION OFALLERGY IN ANESTHESIA

CLINICAL HISTORYCOMPATIBLE

LATEX FREEENVIRONMENTAVOIDMYORELAXANTSHISTAMINE-RELEASINGDRUGS

CONSULTATION OFALLERGO IN ANESTHESIA

OTHER DIAGNOSTTO BE CONSIDERE

HISTORY OF ATOPY, ALLERGYSKIN TESTS: ALL SUSPECTED DRUGS AND

RELATED (CROSS SENSITIZATION)

BLOOD MEASUREMENTS IgE.

YES NO

IDENTIFIEDUNKNOWN

PLANNED SURGERY

PREVIOUS ANAPHYLACTIC REACTION DURING ANESTHESIA

TREATMENT OF ANAPHYLACTIC SHOCK


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DURING ANESTHESIA

1. STOP INJECTION OR INFUSION WHEN POSSIBLE

2. ADVISE THE SURGICAL TEAM DECISION

Abstention Simplification

Acceleration or arrest of surgery

3. OXYGEN: FiO2 = 1

4. CONTROL OF THE AIRWAY, IF NOT YET DONE VENOUS ACES

5. EPINEPHRINE IV Grade 1 Not necessary

Grade 2 Bolus 10 20 g by titration

Grade 3 Bolus 100 200 g by titration

Grade 4 cardiac arrest chest compressions

epinephrine: 1 mg IV AT EACH PHASE OF CPR FOLLOWEDBY IV INFUSION (0.005-0.1 g.kg-1min-1)

vascular filling: cristalloids (30 ml.kg-1)ethylstarch (30 ml.kg-1)

SPECIAL CASES


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SPECIAL CASES

Salbutamol by nebulizer

When severe or resisting to the treatment

Salbutamol IV

Bolus 100 200 g

Infusion 5 - 25 g.min

Epinephrine by IV infusion

Corticosteroids are not immediately efficient

BRONCHOSPASM

Ephephrine 10 g IV every 1-2 minutes up to 0.7 mg/kg-1

If insufficient Epinephrine

PREGNANT WOMAN

Increased doses of epinephrine x 2- 5 times

Add eventualy glucagon 1 2 mg IV

In case of severe cardiovascular collapse refractory to EpinephrineNore hne hrine 0.1 .k -1.min-1

PATIENTS TREATED BY BETA BLOCKERS

CONCLUSIONS


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CONCLUSIONS

EVEN RARE AND SOMETIMES SUBJECT TO CONTROVERSIESTHE ANAPHYLAXY DURING SURGERY IMPLIES :

1. To test all patients and only the patients having an history of

anaphylactic reactionspecialised consultations of allergy in anaesthesia

2. When there is an allergy suspected to one myorelaxant test allrisk of cross sensitization

3. Be prepared to treat:

protocols of treatments (posters in or simulators)

kits of blood sampling

drugs ready to use

4. Prophylaxy is based exclusively on:

anesthesia without myorelaxant

latex free equipment and material

information + + + patient (card), team

there is no efficient premedication

Allergic Reactions to Anaesthetic Drugs[1]

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