Integrating basophil activation tests into evaluation of perioperative anaphylaxis to neuromuscular blocking agents

Li, Jamma; Best, O. Giles; Rose, Michael; Green, Sarah L.; Fulton, Richard B.; Fernando, Suran L.

doi:10.1016/j.bja.2019.02.024

Cited by 17 publications

(29 citation statements)

References 29 publications

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“…101 114,115 BAT has shown positive results in patients with negative STs in several groups of drugs such as PPIs, increasing sensitivity from 67% to 87% 116 ; AX-CLV, up to 91% 114 ; or NMBA up to 77%. 117 However, a retrospective study including patients with IRs to NMBA indicated that BAT does not increase the accuracy of STs. 118 An approach to increase in vitro test sensitivity is the inclusion of drug metabolites besides the native drug.…”

Section: Irs In Vitro Testsmentioning

confidence: 99%

Recent developments and highlights in drug hypersensitivity

Mayorga

Fernandez

Montañez

et al. 2019

Allergy

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Drug hypersensitivity reactions (DHRs) are nowadays the third cause of allergy after rhinitis and asthma with a significant increase in prevalence in both adults and paediatric population with new drugs included as culprit. For this, DHRs represent not only a health problem but also a significant financial burden for affected individuals and health systems. Mislabelling DHRs is showing to be a relevant problem for both, false label of drug allergic and false label of nonallergic. All this reinforces the need to improve accurate diagnostic approaches that allow an appropriate management.Moreover, there is a need for training both, nonallergist stakeholders and patients to improve the reaction identification and therefore decrease the mislabelling. The use of allergy cards has shown to be relevant to avoid the induction of DHRs due to the prescription of wrong medication.Recent developments over the last 2 years and highlights about risk factors, diagnostic approaches, mechanisms involved as well as prevention actions, and management have been reviewed. In these papers, it has been outlined the need for correct diagnosis and de-labelling of patients previously false-reported as allergic, which will improve the management and treatment of patients with DHRs. K E Y W O R D Sallergy diagnosis, allergy treatment, basic mechanisms, drug allergy, epidemiology | 2369

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Section: Irs In Vitro Testsmentioning

confidence: 99%

Recent developments and highlights in drug hypersensitivity

Mayorga

Fernandez

Montañez

et al. 2019

Allergy

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“…In the concentration, we have used in our patient, there is still small possibility of false-negative results in IDT. e efficacy of in vitro tests such as identification of the specific IgE against NMBA and BAT was proposed in recent studies; however, the negative predictive value is higher in skin testing compared with in vitro testing [11][12][13]. Leysen et al suggested that quantification of specific IgE [6,7].…”

Section: Discussionmentioning

confidence: 99%

Skin Testing to Identify Safe Drugs for Patients with Rocuronium-Induced Anaphylaxis

Suzuki¹,

Kawase

Ogita

et al. 2020

Case Reports in Anesthesiology

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Among patients who develop anaphylaxis during anesthesia, anaphylaxis caused by a neuromuscular blocking agent has the highest incidence. In patients who developed IgE-mediated anaphylaxis, and cross-reactivity among NMBAs is a concern in subsequent anesthetic procedures. We present a patient who developed rocuronium-induced anaphylaxis in whom the skin prick test (SPT) and intradermal test (IDT) could identify a safe drug to use in the subsequent anesthetic procedure. A 32-year-old female developed anaphylactic shock at the induction of general anesthesia. She recovered by administration of hydrocortisone and epinephrine. Skin tests including the SPT followed by the IDT revealed rocuronium as the drug that caused anaphylaxis and vecuronium as a safe drug to use for the subsequent general anesthesia. She safely underwent surgery with general anesthesia using vecuronium one month after the skin testing. There are not many reports on the effectiveness of the SPT followed by IDT in identifying the causative drug as well as a safe drug to use in the subsequent anesthetic procedure following anaphylaxis during anesthesia. The usefulness of the SPT should be re-evaluated.

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“…However, BAT is likely to be of value in selected patients with a compelling clinical history of anaphylaxis accompanied by an elevated acute serum total tryptase where skin tests prove to be negative (51). This view has been strengthened by a subsequent study in patients with NMB-associated anaphylaxis, where BAT exhibited a sensitivity of 77% and specificity of 76% (52).…”

Section: Investigation Of Suspected Peri-operative Anaphylaxismentioning

confidence: 97%

Peri-Operative Anaphylaxis—An Investigational Challenge

Misbah

Krishna

2019

Front. Immunol.

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Patients with suspected peri-operative anaphylaxis (POP) require thorough investigation to identify underlying trigger(s) and enable safe anesthesia for subsequent surgery. The changing epidemiology of POP has been striking. Previous estimates of the incidence of POP have ranged between 1:6,000 and1:20,000 anesthetics, but more recent data from France and the United Kingdom suggest an estimated incidence of 1:10,000. Other important changes include a change in the hierarchy of well-recognized triggers, with antibiotics (beta-lactams) supplanting neuromuscular blockers (NMB) as the leading cause of POP. The emergence of chlorhexidine, patent blue dye, and teicoplanin as important triggers have also been noteworthy findings. The mainstay of investigation revolves around critical analysis of the time-line of events leading up to anaphylaxis coupled with judicious skin testing. Skin tests have limitations with respect to unknown predictive values for most drugs/agents and therefore, knowledge of background positivity in healthy controls, test characteristics of individual drugs and the use of non-irritant concentrations is essential to avoid both false-positive and false-negative results. Specific IgE assays for individual drugs are available only for a limited number of agents and are not a substitute for skin testing. Acute serum total tryptase has a high specificity and positive predictive value in IgE-mediated POP anaphylaxis but is limited by its moderate sensitivity and negative predictive value. Planning for safe anesthesia in this group of patients is particularly challenging and consequently anesthetists need to be alert to the possibility of repeat episodes of anaphylaxis. Because of the limitations of current investigations for POP, collecting systematic data on the outcome of repeat anesthesia is valuable in validating current investigatory approaches. This paper reviews the changing epidemiology of POP with reference to the main triggers, and the investigation and outcome of subsequent anesthesia.

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Integrating basophil activation tests into evaluation of perioperative anaphylaxis to neuromuscular blocking agents

Cited by 17 publications

References 29 publications

Recent developments and highlights in drug hypersensitivity

Recent developments and highlights in drug hypersensitivity

Skin Testing to Identify Safe Drugs for Patients with Rocuronium-Induced Anaphylaxis

Peri-Operative Anaphylaxis—An Investigational Challenge

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