Anaphylaxis During the Perioperative Period

Hepner, David L.; Castells, Mariana

doi:10.1213/01.ane.0000082993.84883.7d

Cited by 348 publications

(295 citation statements)

References 125 publications

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“…Although there is no precisely established dosage or regimen for intravenous epinephrine in anaphylaxis, 5-to 10-mg intravenous bolus (0.2 mg/kg) doses for hypotension and 0.1 to 0.5 mg administered intravenously in the presence of cardiovascular collapse have been suggested. 19 A recent single-center trial described successful initial management with intravenous epinephrine infusions for anaphylaxis with hypotension, suggesting that this might be a viable strategy. 10,20 Detailed procedures for the preparation and administration of epinephrine infusions have been published.…”

Section: Epinephrinementioning

confidence: 99%

Second symposium on the definition and management of anaphylaxis: Summary report—Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium

Sampson

Muñoz-Furlong²,

Campbell

et al. 2006

Journal of Allergy and Clinical Immunology

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Section: Epinephrinementioning

confidence: 99%

Second symposium on the definition and management of anaphylaxis: Summary report—Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium

Sampson

Muñoz-Furlong²,

Campbell

et al. 2006

Journal of Allergy and Clinical Immunology

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1,931

1,114

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“…In many countries neuromuscular blocking drugs are the most common agents responsible for anaphylaxis during general anaesthesia, with rocuronium being one of the most frequently implicated [1,2]. One of the basic principles in the management of anaphylaxis is the removal of the triggering agent [3].…”

Section: Accepted: 23 October 2011mentioning

confidence: 99%

The role of sugammadex in the development and modification of an allergic response to rocuronium: evidence from a cutaneous model*

Clarke¹,

Sadleir²,

Platt³

2012

Anaesthesia

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SummaryThe availability of sugammadex as a selective encapsulating agent for rocuronium has led to speculation that it may be useful in mitigating rocuronium-induced anaphylaxis. Off-label use of sugammadex for this indication has already been documented in case reports although there are theoretical objections to the likelihood of an allergen-binding agent's being able to attenuate the immunological cascade of anaphylaxis. Using a cutaneous model of anaphylaxis in rocuronium-sensitised patients, we were unable to demonstrate that sugammadex was effective in attenuating the type-1 hypersensitivity reaction after it has been triggered by rocuronium, but we were able to demonstrate that these patients are anergic to sugammadex-bound rocuronium. These findings demonstrate that a cyclodextrin can bind an allergen and exclude it from interacting with the immune system, and may potentially lead to novel applications in other allergic diseases. However, there is no evidence that sugammadex should be used for the treatment of rocuronium-induced anaphylaxis, and clinical management should follow established protocols. Accepted: 23 October 2011In many countries neuromuscular blocking drugs are the most common agents responsible for anaphylaxis during general anaesthesia, with rocuronium being one of the most frequently implicated [1,2]. One of the basic principles in the management of anaphylaxis is the removal of the triggering agent [3]. However, although there is evidence that the removal of an allergen from its corresponding cell-bound-specific antibody will attenuate the process of mediator release from the mast cell in vitro [4], there is no evidence that it will alter the clinical course of anaphylaxis in vivo.Sugammadex is a modified c-cyclodextrin with a hydrophobic cavity designed to encapsulate rocuronium and other steroid-based neuromuscular blocking drugs [5]. Intermolecular (van der Waals) forces result in a water-soluble complex with a high association rate. When used for the reversal of rocuronium-induced neuromuscular blockade, sugammadex is very effective [6]. Sugammadex is rapidly distributed to the effect compartment [7], its affinity for rocuronium is greater than that of the nicotinic acetylcholine receptor [8], and the influence of rocuronium at the nicotinic acetylcholine receptor is both reversible and relatively insensitive [9]. Consequently, sugammadex has been shown to reverse profound rocuronium-induced neuromuscular blockade within minutes [6].

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“…46 Last, it should be noted that patients with a true penicillin allergy are more likely to experience an anaphylactic reaction to other drugs. 59 …”

Section: Choice Of Antibioticmentioning

confidence: 99%

The Anesthesiologist's Role in the Prevention of Surgical Site Infections

Mauermann

Nemergut²

2006

Anesthesiology

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This article has been selected for the Anesthesiology CME Program. After reading the article, go to http:// www.asahq.org/journal-cme to take the test and apply for Category 1 credit. Complete instructions may be found in the CME section at the back of this issue.SURGICAL site infections (SSIs) continue to be a substantial source of morbidity and mortality in the surgical patient population. They are the second most common cause of nosocomial infection after urinary tract infections and account for approximately 17% of all hospital-acquired infections. 1 These infections lead to longer hospital and intensive care unit stays, lead to substantially increased mortality, and contribute significantly to healthcare costs. 2 In a 1999 series of cardiac surgery patients, each deep sternal wound infection added an average of $26,400 in hospital charges and increased the average duration of stay by 16 days. 3 The incidence of SSI varies for each operative procedure, each surgeon, and each hospital. In addition, each patient presents with his or her own unique risk profile for the development of a SSI. Although sterile surgical technique is extremely important to the prevention of SSIs, there is increasing evidence that anesthesiologists play a prominent yet under appreciated role in the prevention of SSIs. While infections typically present several days postoperatively, the first few hours after bacterial contamination are the critical window for the establishment of infection. 4,5 Therefore, decreasing SSIs hinges on the optimization of perioperative conditions, many of which are controlled by anesthesiologists.In this review, we will discuss the literature surrounding six perioperative factors over which anesthesiologists have at least partial control and how these factors may influence the risk of postoperative surgical site infection. Although we acknowledge that many anesthesiologists care for patients in the intensive care unit, we limit our discussion here to the immediate perioperative period. HypothermiaMild perioperative hypothermia (core body temperature 34°-36°C) is commonly observed in surgical patients. The complications of mild perioperative hypothermia have been studied extensively and include increased duration of hospitalization, 5 increased intraoperative blood loss and transfusion requirements, increased adverse cardiac events, and an increase in patient thermal discomfort in the recovery room. 6 The effects of mild hypothermia on SSI have also been studied.A series of 200 patients undergoing colorectal surgery were randomized to a hypothermic group (34.4°Ϯ 0.4°C) or a normothermic group (37°Ϯ 0.3°C) and followed for 2 weeks postoperatively. 5 The authors had planned to enroll 400 patients; however, the trial was stopped early because of a statistically significant difference in infection between the two groups. The incidence of SSI was 5.8% in the normothermic group and 18.8% in the hypothermic group. The patients who developed SSIs required hospital stays nearly 1 week longer than those who did not d...

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Anaphylaxis During the Perioperative Period

Cited by 348 publications

References 125 publications

Second symposium on the definition and management of anaphylaxis: Summary report—Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium

Second symposium on the definition and management of anaphylaxis: Summary report—Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium

The role of sugammadex in the development and modification of an allergic response to rocuronium: evidence from a cutaneous model*

The Anesthesiologist's Role in the Prevention of Surgical Site Infections

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