Perioperative management of anaphylactic reactions
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PERIOPERATIVE MANAGEMENT
OF
ANAPHYLACTIC REACTIONS
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PROF. MRIDUL M. PANDITRAO
CONSULTANTDEPARTMENT OF ANESTHESIOLOGY AND
CRITICAL CARERAND MEMORIAL HOSPITAL
FREEPORTGRAND BAHAMA
THE COMMONWEALTH OF BAHAMAS
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1. Importance of Diagnosis.2. Goals of Diagnosis 3. Risk factors in patients.4. Suppression of Mediators
Release.5. Tests to be done at the time of
reaction.6. Tests to be done 4-6 weeks
after reaction.7. Documentation & Medico legal
Implications.8. Pre anesthetic testing.
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IMPORTANCE OF DIAGNOSIS
1. Epidemiological.
2. Medico legal.
3. To prevent reactions in subsequent anesthetics.
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GOALS OF DIAGNOSTIC TESTING
1.Cause of reaction.
2. To pinpoint a specific drug.
3. Which other drug could produce similar reaction.
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RISK FACTORS IN PATIENTS
1. Rare in neonates and Geriatrics
2. Rare in Shock states
3.Behavioral changes in mast cells
4. Low levels of Renin Angiotensin systems
5. Relation with h/o Atopy or Allergy
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RISK FACTORS IN PATIENTS (CONTD)
6. Female : Male – 4:1 ↑ IgA, IgM, IgG → Polio virus & bovine albumine
Female Sex hormones- Prolactin ↑ses Cell mediated responses
Androgenic hormones- Immunosuppressive
7. Previous exposure- not important
8. β blocked patients – Difficult to treat Needs ↑ doses
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SUPPRESSION OF MEDIATOR RELEASE
1. Adenyl cyclase- ↑ cAMP synthesis →↓ mast cell degranulation. Prostaglandins, histamine ( small doses ) & β agonists ↑ adenyl cyclase. Epinephrine acts via β receptors.
2. Corticosteroids act → cytokines →↓ mast cell activity.
3. Phosphodiesterase inhibitors→ ↑cAMP by inhibiting its breakdown.
4. Disodium cromoglycate inhibits Ca influx into cell & prevents initiation of response.
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TESTS PERFORMED DURING REACTION
1.Plasma histamine: 0-1ng/ml. Half life is only 10 minutes. Level > 20ng/ml shows histamine involved reaction.
2. Urinary Methyl Histamine : 0-118mcg/24hours sample 10 in 10 patients →↑ plasma histamine. 4 in 10 patients →↑ urinary methyl histamine.
3. Immunoglobulin E levels-↑ indicates reaction. * Drug specific IgE.
4. Complement levels is serum : 55-110ng/ml.
5. Mast Cell Tryptase- 10ng/ml (2-23ng/ml). 25% of Mast Cell protein- degranulation – liberated. Half life- 90 min. 1 hrs, 6 hrs & 24 hrs- sensitive test.
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TESTS DONE 4-6 WEEKS AFTER THE REACTION
Time allowed to normalize.
All drugs used should be tested.
Patient to be made aware.
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SKIN TESTING
Main stay in our hands as labs are distant.
Skin of back and anterior face of forearm.
h\o anaphylaxis- positive for plasma H, Tryptase, Urinary Methyl H.
Operation Theatre Complex- Resuscitation measures , Drugs, IV fluids, Equipment.
Monitors – pulse, BP, resp, O2 saturation.
Sweating /discomfort.
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CONTD.
0.4% phenol in saline- negative - < 2-4mm dia 9% codeine phosphate- positive- > 15mm dia Drug test positive- wheal > 7-8mm dia Each prick test – observed 15 minutes . Next drug- 30 mins after previous. 2 drugs on each forearm/ day. Injection site examined 12-24 hrs- late
reaction. Not useful for colloids & contrast media. Cross sensitivity should also be tested.
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2 TYPES OF SKIN TESTING
Intra dermal injection-1 in 100 con of drug used - flare or wheal. If negative- Less dilutions may be tried in strongly suggestive case with caution.
Prick test- drop of undiluted drug placed on forearm- prick with sterile needle through drop.
Moderate to severe reactions-seen & treated. No death on skin testing reported as yet.
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RADIO IMMUNO ASSAY
Reflects IgE bound to mast cells.
Antigen ( drug) + patient’s serum – incubated- antigen antibody complex formed.
Complex + radio labeled anti IgE – incubated bound radioactivity assessed.
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SKIN TEST+ RIA- CONCLUSIONS
ST more specific than RIA- particular drug.
Drug specific RIA – not available for all drugs.
ST+RIA- preferable. Cross sensitivity – better with RIA. Thio and NMBD.
LEUCOCYTE & BASOPHIL- H - not specific.
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MEDICO LEGAL IMPLICATIONS
CLEAR DUTIES1. Diagnose & treat.2. Investigations in immediate, postop 4-6
weeks as per availability.3. Skin testing – 4-6 weeks. All drugs and cross.4. Documentation: all events – intra - post –
late post op on case paper& main hospital records.
5. Communicate results to patients and relatives . Durable card / warning plate- all details.
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SUBSEQUENT ANAESTHESIA
• After listening to these tests - All patients- skin test & RIA.
• No predictive value. Not practical.
PRE-ANAESTHETIC TESTING:• Done in patients with positive H/O reaction during
anaesthesia or any treatment.• Possible in elective- but not in emergency.• Testing schedule:
History, previous records – study & document. Skin testing planned – all precautions . All drugs to be
used, cross sensitivity. All testing negative – does not rule out possibility. All
precautions & resuscitative measures -ready.
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PREFERENCES
• Premedication- fentanyl, pethidine over morphine.
• Induction- ketamine/ propofol /thiopentone.• Inhalational anaesthesia preferred over TIVA.• Regional anaesthesia- lesser no. of drugs, less
sensitivity to local anaesthetic.• Prefer Starches over Haemacoel. • Preventive measures – corticosteroids,
disodium cromoglycate, β agonists, epinephrine.
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EMERGENCY CASES
No time for testing. If previous records available – avoid
those drugs other preferences as per the routine
cases. ketamine / propofol / thiopentone Mivacurium / pancuronium / vecuronium Inhalational better than TIVA. Regional anaesthesia better than
general anaesthesia.
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Thank You
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FUTURE DEVELOPMENTS
• Rare event so simulated anaphylaxis drill – practical
• Desensitization by exposure to increasing doses still inconclusive.
• More efficient H receptor blockers & other mediator blockers.
• Safer drug designing eliminating anaphylaxis component.
• Methods to measure trigeriness of mast cell.• Measurement of circulating IL-4,5, still distant
possibility.