Scandinavian Clinical Practice Guidelines on the diagnosis, management and follow‐up of anaphylaxis during anaesthesia*

Abstract

The present approach to the diagnosis, management and follow‐up of anaphylaxis during anaesthesia varies in the Scandinavian countries. The main purpose of these Scandinavian Clinical Practice Guidelines is to increase the awareness about anaphylaxis during anaesthesia amongst anaesthesiologists. It is hoped that increased focus on the subject will lead to prompt diagnosis, rapid and correct treatment, and standardised management of patients with anaphylactic reactions during anaesthesia across Scandinavia. The recommendations are based on the best available evidence in the literature, which, owing to the rare and unforeseeable nature of anaphylaxis, mainly includes case series and expert opinion (grade of evidence IV and V). These guidelines include an overview of the epidemiology of anaphylactic reactions during anaesthesia. A treatment algorithm is suggested, with emphasis on the incremental titration of adrenaline (epinephrine) and fluid therapy as first‐line treatment. Recommendations for primary and secondary follow‐up are given, bearing in mind that there are variations in geography and resources in the different countries. A list of National Centres from which anaesthesiologists can seek advice concerning follow‐up procedures is provided. In addition, an algorithm is included with advice on how to manage patients with previous suspected anaphylaxis during anaesthesia. Lastly, provides an overview of the incidence, mechanisms and possibilities for follow‐up for some common drug groups.

Suspected anaphylaxis from intravenous cefazolin during general anaesthesia in a dog

“…This classification describes four grades of increasing severity: I; cutaneous-mucous signs (e.g. urticaria), II; moderate multivisceral signs (involvement Tachycardia and hypotension are usually observed, though bradycardia (resulting from the Bezold-Jarisch reflex) may occur in up to 10% of cases during general anaesthesia (Dewachter et al 2009, Harper et al 2009, Kroigaard et al 2007). …”

Anaesthesia-associated hypersensitivity reactions: seven years' data from a British bi-specialty clinic

“…Only 173 (54.7%) patients with suspected hypersensitivity reaction referred to our clinic had bloods taken for serum tryptase measurement. An important message to clinicians who refer patients with suspected hypersensitivity reactions is to ensure blood samples are taken for serum tryptase analysis according to recommended time intervals [1][2][3][4]. Indeed, a recent editorial suggested that even more samples should be taken, for example at one, two, three, six, 12 and 24 hours after a reaction, to ensure that at least some of these samples reach the laboratory and demonstrate the rise and fall of serum tryptase concentrations [41].…”

“…The referral of patients with suspected hypersensitivity reactions to anaesthetic drugs for further investigations is now considered mandatory, and is the responsibility of the primary anaesthetist involved [2][3][4]. A study from 2005 showed that an informed guess was not a reliable way of determining the cause of a suspected hypersensitivity reaction during anaesthesia, and may put a significant number of patients at unnecessary risk [5].…”

Practical Guidelines for Perioperative Hypersensitivity Reactions

“…Many of the drugs administered during the perioperative period such as antibiotics or NSAIDs will be studied following regular procedures and are not going to be described in this review. However, DPT with perioperative drugs has added several limitations and there is not a consensus procedure for its performance (grade of recommendation, C) [10,145,146]. The final goal is to reach a total dose of the drug needed for anaesthetic induction (propofol, etomidate, ketamine), or during the anaesthetic procedure (opioids, midazolam...).…”