Australian and New Zealand Anaesthetic Allergy Group Perioperative Anaphylaxis Investigation Guidelines

Abstract

These guidelines are a consensus document developed by a working party of the Australian and New Zealand Anaesthetic Allergy Group (ANZAAG) to provide an approach to the investigation of perioperative anaphylaxis. They focus primarily on the use of skin testing as it is the investigation with the greatest clinical utility for the identification of the likely causative agent and potentially safer alternatives. The practicalities and process of skin testing, its limitations, and the place of other tests are discussed. These guidelines also address the roles of graded challenge and in vitro testing. The implications of anaphylaxis associated with neuromuscular blocking agents, beta-lactam antibiotics, local anaesthetic agents and chlorhexidine are discussed. Evidence for the recommendations is derived from literature searches using the words skin test, allergy, anaphylaxis, anaesthesia, and each of the individual agents listed in these guidelines. The individual articles were then reviewed for suitability for inclusion in these guidelines. Where evidence was not strong, as is the situation for many perioperative agents, expert consensus from the ANZAAG working party was used. These guidelines are intended for use by specialists involved in the investigation of perioperative allergy. They have been approved following peer review by members of ANZAAG and are available on the ANZAAG website: http://www.anzaag.com/anaphylaxis-management/testing-guidelines.pdf.

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

“…NAP6 data shows rapid falls within 30 minutes and support BSACI and AAGBI Guidelines (1st sample immediately post‐reaction, 2nd at 1‐2 hours, plus a 24‐hour baseline . Second samples within 6 hours can still be informative (ANZAAG guidelines suggest 1‐, 4‐ and 24‐hour samples) …”

“…20,24 Second samples within 6 hours can still be informative (ANZAAG guidelines suggest 1-, 4-and 24-hour samples). 2,14 Ten per cent had elevated baseline tryptase suggesting mastocytosis or raised alpha tryptase due to gene duplication now sometimes referred to as hyper-alpha tryptasaemia syndrome (HATS). 26 It is impossible to verify that these are truly raised, due to the variation in baseline sampling and lack of follow-up samples.…”

“…• Tryptase release is seen in most but not all cases of perioperative anaphylaxis, most commonly in the higher grades of reaction (Grade 3-5). [2][3][4][5][6][7][8][9] • There is a poor correlation with reaction grade individually, but higher medians are seen in more severe reactions. 3 • Tryptase levels plateau between 30 and 90 minutes post-reaction.…”

An update on allergy and anaphylaxis in pediatric anesthesia

“…The consultation includes the review of the nature and timing of the clinical reaction and all agents used intraoperatively as well as tryptase results. Skin prick and intradermal testing induce localized mast cell degranulation and a wheal and flare response which identifies IgE‐mediated hypersensitivity . International guidelines for perioperative allergy testing are published .…”

“…Skin prick and intradermal testing induce localized mast cell degranulation and a wheal and flare response which identifies IgE‐mediated hypersensitivity . International guidelines for perioperative allergy testing are published . Skin prick testing is highly sensitive for NMBDs but insensitive for antibiotics, barbiturates, benzodiazepines, and opiates .…”