A 17‐year experience in perioperative anaphylaxis 1998–2015: harmonizing optimal detection of mast cell mediator release

Abstract

Summary Background Sheffield NARCOS (National Adverse Reactions Advisory Service) investigates suspected perioperative anaesthetic reactions using serial tryptase, urinary methylhistamine (UMH) and clinical information. Further recommendations for additional allergy clinic assessment are provided. Objective To establish a robustly measurable protocol for identifying mast cell mediator (MMR) release in this cohort. To compare these thresholds with previously suggested thresholds and algorithms. Method A review of 3455 NARCOS cases referred with a suspected perioperative allergic reaction. Tryptase, UMH and clinical details were analysed. A total of 1746 cases were graded using the Ring and Messmer scale. Reaction grade, tryptase and UMH changes were compared with statistical and graphical presentations appropriate to non‐normally distributed measurements using Analyse‐IT software. Results Sensitive strategies such as 3 μg/L or 20% are measurable and translatable and would substantially increase detection of potentially relevant changes in tryptases. Adequate quality assurance for low‐level measurement is needed. An incremental threshold of 20% would identify potential MMR in an additional 14% of cases with peak tryptase (Tp) between 5 and 14 μg/L and a further 15% with Tp below 5 μg/L. Further work is required to establish the diagnostic performance characteristics of this more sensitive approach. UMH also identified up to 120 further cases of potential MMR in the absence of tryptase increments. Conclusions and Clinical Relevance Future studies should establish and compare the predictive performance characteristics of each strategy against clinical phenotypes. A single agreed definition of positive serial tryptases is needed to enable robust evaluation of diagnostic strategies. This could serve as a harmonized standard for comparative studies of case series from different centres.

Specialist perioperative allergy clinic services in the UK 2018: Results from the Royal College of Anaesthetists Sixth National Audit Project (NAP6) investigation of perioperative anaphylaxis

“…Approximately 400‐600 Grade 3‐5 cases are expected annually in the UK, similar to previously reported estimates and the NAP6 baseline survey . NAP6 received 266 completed and interpretable 2‐part reports from the UK.…”

“…NAP6 received 266 completed and interpretable 2‐part reports from the UK. This suggests some under‐reporting …”

“…Tryptase levels plateau between 30 and 90 minutes post‐reaction Dynamic tryptase results may identify tryptase release in more cases than exceeding fixed thresholds of 11.4 or 14 μg/L Exposure to opioids such as pholcodine may correlate with neuromuscular blocking agent (NMBA) anaphylaxis.…”

Hypersensitivity Reactions During Anaesthesia Care: An 11-Year Experience From A Tertiary Hospital

“…This is a suboptimal way of determining the responsible drugs, since during anesthesia, several drugs are administered in consecutive moments. There are also other factors that mimic the clinical picture of anaphylaxis, including direct mast cell mediator release and other causes of hypotension and bronchospasm, including the pharmacological action of the anesthetic drugs themselves [17].…”

The national perioperative anaphylaxis audit project

“…The National Audit Project 6 perioperative anaphylaxis final report was launched on 14 May 2018 . The project has collected comprehensive information on perioperative anaphylactic events to facilitate collaboration between anaesthetics and allergy to improve patient care. A total of 266 cases met the inclusion criteria between 2015 and 2016.…”