Management of suspected immediate perioperative allergic reactions: an international overview and consensus recommendations

Abstract

Suspected perioperative allergic reactions are rare but can be life-threatening. The diagnosis is difficult to make in the perioperative setting, but prompt recognition and correct treatment is necessary to ensure a good outcome. A group of 26 international experts in perioperative allergy (anaesthesiologists, allergists, and immunologists) contributed to a modified Delphi consensus process, which covered areas such as differential diagnosis, management during and after anaphylaxis, allergy investigations, and plans for a subsequent anaesthetic. They were asked to rank the appropriateness of statements related to the immediate management of suspected perioperative allergic reactions. Statements were selected to represent areas where there is a lack of consensus in existing guidelines, such as dosing of epinephrine and fluids, the management of impending cardiac arrest, and reactions refractory to standard treatment. The results of the modified Delphi consensus process have been included in the recommendations on the management of suspected perioperative allergic reactions. This paper provides anaesthetists with an overview of relevant knowledge on the immediate and postoperative management of suspected perioperative allergic reactions based on current literature and expert opinion. In addition, it provides practical advice and recommendations in areas where consensus has been lacking in existing guidelines.

5-Aminolevulinic acid-induced severe hypotension during transurethral resection of a bladder tumor: a case report

“…We also suspected anaphylaxis caused by propofol or rocuronium, as hypotension did not respond to conventional drugs such as ephedrine and phenylephrine. Hypotension, bronchospasm, angioedema, and dermatological symptoms are common clinical signs of perioperative allergic reactions [11]. In our case, hypotension was the only symptom.…”

“…A recent review reported that it is important to consider anaphylaxis as a differential diagnosis when perioperative hypotension or bronchospasm do not respond to conventional therapy during general anesthesia [11]. We also suspected anaphylaxis caused by propofol or rocuronium, as hypotension did not respond to conventional drugs such as ephedrine and phenylephrine.…”

Anaphylaxis caused by butylscopolamine bromide: a case report

“…In our case, we found a marked increase in serum tryptase at 1 h after the reaction (174 μg/L) compared to the baseline level (2.1 μg/L). Since an increase in serum tryptase at the time of a suspected reaction to above 1.2 × baseline + 2 μg/L is considered clinically relevant [15], the results suggested the occurrence of a strong hypersensitivity reaction. Significant elevation of plasma histamine levels at 1 h after the reaction (271.7 nmol/L) compared to baseline levels (6.3 nmol/mL) also supported our diagnosis.…”

Medical algorithms: Diagnosis and investigation of perioperative immediate hypersensitivity reactions

“…National Audit Project (NAP6), 2 and in recent publications from European and international working groups making recommendations on the management and investigation of perioperative hypersensitivity reactions. 1,3 In the following, two algorithms are presented based on recent hypersensitivity. In some cases, an allergic mechanism is not obvious and tryptase may not be elevated, or not taken.…”

“…Once it has been decided that an allergic mechanism is likely or cannot be ruled out, a The presented algorithms are a truncated version of recommendations made in the 2019 EAACI position paper 1 and other recent international publications. [2][3][4][5][6][7] Work in this field was initiated in France 8 and Australia, 6 and is now expanding rapidly with increasing international collaborations. This publication provides an overview only, and more detailed information can be found in the referenced guidelines and articles.…”