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Suspected anaphylactic reactions associated with anaesthesia ..................................................................................................................................... IgE-mediated reaction [2]. Anaphylactoid reactions are defined as those reactions that produce the same clinical picture as anaphylaxis but are not IgE mediated.’ In these guidelines we will follow the European (EAACI) nomenclature. Anaphylaxis is not a homogeneous process: the pathways, mediators, time course and response to treatment depend on the trigger agent, its route and rate of administration, the nature of the patient’s hypersensitivity and the state of health of the patient, including incidental pathology such as respiratory or cardiovascular disease and the effects of concomitant medication such as b-blockers and ACE inhibitors. Although anaphylaxis commonly involves respiratory, cutaneous and circulatory changes, variations such as shock with gastrointestinal disturbance or shock alone are possible. Alternatively, reactions may be fatal without significant shock except as the terminal event following respiratory arrest [3]. Angioedema and urticaria may be features of anaphylaxis but commonly result from mechanisms other than anaphylaxis. Intravascular volume redistribution is an important component of anaphylactic shock. Cardiac output may be decreased as a result of reduced coronary artery perfusion pressure as well as impaired venous return. Local release of mediators may cause coronary artery spasm and there may be features of acute left or right ventricular failure. Myocardial ischaemia with ECG changes is expected within minutes of anaphylactic shock becoming severe. Asphyxia may be due to upper airway occlusion caused by angioedema, or bronchospasm with mucus plugging of the lower airways; the latter most commonly occurs in patients taking daily treatment for asthma. Both these processes may occur simultaneously in patients reacting to foods, latex, b-lactam antibiotics or aspirin. Anaphylaxis usually resolves in 2–8 h but secondary pathology arising from the reaction or its treatment may prolong this. Resolution is complete except when cerebral hypoxia at the peak of the reaction has caused significant brain damage, or when disordered clotting leads to bleeding. Acknowledgements The involvement of the British Society for Allergy and Clinical Immunology and the Clinical Immunology and Allergy section of the British Society for Immunology is gratefully acknowledged. In addition, the working party wishes to acknowledge the assistance of the following: Ó 2009 The Authors 4 Journal compilation Ó 2009 The Association of Anaesthetists of Great Britain and Ireland
Suspected anaphylactic reactions associated with anaesthesia ..................................................................................................................................... Sr Alex Farragher Specialist Immunology Nurse Mr Chris Hirst AAGBI Anaphylaxis website designer Dr David Noble Dr Martin Shields References 1 Johansson SGO, Bieber T, Dahl R, et al. Revised nomenclature for allergy for global use: Report of the Nomenclature Review Committee of the World Allergy Organization, October 2003. Journal of Allergy and Clinical Immunology 2004; 113: 832–6. 2 Joint Task Force on Practice Parameters. The diagnosis and management of anaphylaxis: an updated practice parameter. Journal of Allergy and Clinical Immunology 2005; 115: S483–523. 3 Pumphrey RSH. Lessons for management of anaphylaxis from a study of fatal reactions. Clinical and Experimental Allergy 2000; 30: 1144–50. Epidemiology Geographical variation Most reports on anaesthesia-related anaphylaxis originate from France, Australia, New Zealand and the United Kingdom. Other case series have been described from Scandinavia and the USA. The true incidence and their associated morbidity and mortality remain poorly defined. Both the accuracy and completeness of reporting is not optimal. 10% of anaesthesia-related reactions reported to the UK Medicines Control Agency (MCA) were fatal. These data should be interpreted with caution because it is likely that many less-severe reactions are not reported [1]. Reactions that are accepted as side-effects of certain drugs, for instance, histaminergic reactions due to atracurium and mivacurium, may be underreported. During a time period of over 6 years only 361 reactions were reported to the MCA. In a 2-year period 789 reactions were reported in France in a comparable population where there is a well-established culture of reporting anaesthesia-related reactions [2]. Based on studies in Australia and France, the incidence of anaphylaxis during anaesthesia has been estimated at between 1 in 10 000 and 20 000 [3, 4]. The true incidence of anaphylaxis during anaesthesia in the UK is not known. By extrapolating the French and Australian data to the UK, it is estimated that there are approximately 500 severe reactions in the UK each year. Anaphylactic reactions are more common when drugs are given intravenously. Ó 2009 The Authors Journal compilation Ó 2009 The Association of Anaesthetists of Great Britain and Ireland 5
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