Clinical reasoning in anaphylactic shock: addressing the challenges faced by anaesthesiologists in real time

Abstract

Acute hypersensitivity reactions to drugs occur infrequently during anaesthesia and the peri-operative period. When clinical presentation includes the classical triad, erythema, cardiovascular abnormalities and increased airway pressure, the diagnosis is evident and the challenge is to prescribe a therapeutic regimen according to guidelines and to manage refractory signs in a timely manner. In many situations, however, the initial clinical signs are isolated, such as increased airway pressure or arterial hypotension. Rendering a differential diagnosis with causes and mechanisms other than acute hypersensitivity reactions (AHRs) is difficult, delaying treatment with possible worsening of the clinical signs, and even death, in previously healthy individuals. In these difficult diagnostic situations, clinical reasoning is mandatory, and guidelines do not explicitly explain the elements on which clinical reasoning can be built. In this article, based on clinical evidence whenever available, experimental data and pathophysiology, we propose algorithms that have been evaluated by experts. The goal of these algorithms is to provide explicit elements on which the differential diagnosis of AHRs can be made, accelerating the implementation of adequate therapy.

Camrelizumab-induced anaphylactic shock in an esophageal squamous cell carcinoma patient: A case report and review of literature

“…Anaphylactic shock is a serious life-threatening acute systemic hypersensitivity reaction that is characterized by rapid development of life-threatening bronchospasms, or respiratory failure, or cardiovascular abnormalities. Sometimes, it is accompanied by general urticaria, erythema, and skin itch[ 7 , 8 ]. The symptoms associated with anaphylactic shock usually occur within minutes or less than 1 h after administration of the precipitating drug and result from activation of tissue mast cells and blood basophils, which release histamine and other inflammatory mediators[ 8 ].…”

Anaphylaxis mortality in the perioperative setting: Epidemiology, elicitors, risk factors and knowledge gaps

“…echocardiography) can assist in the decision to assess preload dependency, stroke volume or cardiac output and adjust fluid therapy 33 . Groups of experts have been trying to propose practical reasoning algorithms to support anaesthesiologists manage anaphylactic shock in real life 33,53 …”

“…33 Groups of experts have been trying to propose practical reasoning algorithms to support anaesthesiologists manage anaphylactic shock in real life. 33,53 Given that anaphylaxis is a rare emergency condition, anaesthesiologists should be familiar with the correct recognition of anaphylaxis, specificities in theatre, and the adequate management of PA. Simulation of anaphylaxis scenarios for training health professionals working in perioperative settings has been used for many years in different countries with the aim of optimising this process. 54 However, there is limited evidence on whether simulation training for PA management can really improve patients' management and outcomes.…”

Rocuronium‐Induced Anaphylaxis in the Perioperative Period: A Clinical Review

“…The most severe form of an acute hypersensitivity reaction is anaphylactic shock and involves cardiovascular compromise 12 . Anaphylactic shock is an example of distributive shock and occurs when mediators released from mast cells cause arterial vasodilation leading to a decrease in systemic vascular resistance and thus blood pressure, as well as venous dilation leading to decreased venous return and relative hypovolemia.…”

“…5,7,10 Rocuronium-induced anaphylaxis is a diagnostic challenge because this medication is commonly administered in conjunction with others that also can produce anaphylaxis (eg, antibiotics, induction agents), and it can present during surgery with symptoms that could have multiple causes (eg, hypotension, bronchospasm). 11 However, patient safety concerns dictate that perioperative personnel recognize rocuronium-induced anaphylaxis promptly and treat it correctly 12 because onset occurs rapidly (eg, within minutes) with little warning and it can be life-threatening. Perioperative nurses should have knowledge of this potential complication to participate optimally in its treatment.…”