Endoscopic excision of hydatid cyst: A case of delayed anaphylaxis in postoperative period - “The risk is not over until it is over”

Medicolegal Implications of Biphasic Anaphylaxis

“…2,3,8,13,[24][25][26][27]30,32,62 In cases of fatal biphasic anaphylaxis, the latency time for the onset of the second reaction could be 8, 12, or even 48 hours but appears to be most frequent after 1-2 hours: this would suggest that a close temporal proximity between the initial and second reaction might be an indicator for fatality. 19,33,39,[63][64][65][66][67]…”

“…Because of the absence of standardized research protocols, the literature shows no agreement as to the frequency of biphasic reactions (from 1% to 23% of all anaphylactic cases), with only 11 published cases of fatalities available. [2][3][4][6][7][8][19][20][21][22][23][24][25][26][27][30][31][32][33]38,39,[44][45][46][47][48][49][60][61][62][63][64][65][66][67][68][75][76][77][78][79][80] When a medicolegal evaluation is requested by the courts, a diagnosis of biphasic anaphylaxis in a nonclinical setting proves to be very difficult and can be impossible, whether the patient survived or not. 79 In cases where the patient survived, a forensic evaluation may be needed to ascertain whether the anaphylactic event was managed correctly and to evaluate the outcome, in the event of claims for compensation due to medical malpractice.…”

“…13,79,80,[88][89][90][91][92][93][94][95][96][97][98][99] Studies of biphasic anaphylaxis make it clear that the second reaction, especially cases where death results, often appears around an hour after the primary reaction. [2][3][4][6][7][8]19,[23][24][25][26][27]30,32,33,39,[63][64][65][66][67]73,74,[77][78][79][80]86,90 In 2016, the Working Group of the Resuscitation Council (UK) proposed the following sample timing protocol for the surveillance of tryptase: (1) initial sample as soon as possible after first aid or resuscitation has started; 2) second sample at 1 to 2 hours after the onset of symptoms because its peak concentration has been reported to be reached about an hour after the primary reaction and to disappear with a half-life 2 hours; 3) third sample 24 hours later, this protocol appears to be appropriate for the surveillance of all patients suffering from anaphylaxis, including those experiencing biph...…”

“…- Gupta et al 67 reported 1 case of a child who died because of a surgically removed hydatid cyst (latency 12 hours—second reaction at hospital—death in hospital).…”

“…Many aspects of biphasic anaphylaxis are unclear, with many reports and studies disagreeing on epidemiology, pathophysiology, risk factors, clinical treatment, postacute phase observation, and postdischarge therapies and precautions (the majority of fatal biphasic reactions have been reported as occurring in nonhospital environments). Because of the absence of standardized research protocols, the literature shows no agreement as to the frequency of biphasic reactions (from 1% to 23% of all anaphylactic cases), with only 11 published cases of fatalities available 2–4,6–8,19–27,30–33,38,39,44–49,60–68,75–80 …”