FRCA Notes


Anaphylaxis

In the immediate wake of NAP6, a question on anaphylaxis appeared in the March 2019 SAQ (90% pass rate).

Since then, the Resus Council guidelines have been updated and the AAGBI quick reference handbook published, so the topic may well be re-visited.

Resources


  • Some 30% of patients presenting for surgery have an 'allergy', yet the overwhelming majority are non-anaphylactic and indeed mostly non-allergic full-stop

  • The incidence of bona fide perioperative anaphylaxis is 0.01% (1 in 10,000 anaesthetics)
    • This appears to be somewhat consistent at an international level; the incidence of perioperative anaphylaxis in China is 1 in 11,000 (BJA, 2022)
    • A composite scoring system used in the JESPA study (BJA, 2023) found the incidence in Japan to be 1 in 5,000

  • This makes perioperative anaphylaxis marginally more common than the European incidence of all-cause anaphylaxis (1.5 - 7.9 per 100,000 person years)
  • The Resus Council themselves note that, as anaphylaxis is a clinical diagnosis, "a precise definition is not important for treatment"
  • This may be an unimpressive thing to say in a viva, so you could instead borrow one of the following definitions:
  • A serious systemic hypersensitivity reaction that is usually rapid in onset and may cause death

    An acute, life-threatening type 1 hypersensitivity reaction

  • I.e. anaphylaxis is rapid-onset immune-mediated badness which requires emergent treatment

  • Anaphylaxis is a type 1 hypersensitivity reaction cause by antigens binding to IgE immunoglobulins
  • Initial exposure to an allergen can cause sensitisation and generation of IgE
    • Exposure may be to compounds with molecularly similarity to drugs used in the perioperative period e.g. pholcodine and NMBAs (BJA, 2021)

  • Upon repeat exposure, IgE binds to high-affinity Fc receptors on mast cells (and basophils), causing them to degranulate
    • IgE antibodies also bind to low-affinity Fc receptors on lymphocytes, eosinophils and platelets

  • Mast cells release anaphylatoxins; histamine, prostaglandins, serotonin, tryptase and leukotrienes
  • These mediators are responsible for the physiological effects of anaphylaxis: vasodilation, increase capillary permeability and smooth muscle constriction

  • It's worth noting that adrenaline, by preventing mast cell degranulation via the β2-adrenoreceptor is the treatment for anaphylaxis, not merely a vasoactive agent aiming to reverse the offending vasoplegia

Antibiotics (47%)

  • Beta-lactam antibiotics are overall responsible for the largest number of antibiotic-associated anaphylaxes
    • This includes cephalosporins; cefazolin was the most frequently causative antibiotic in the JESPA study
  • Teicoplanin is 17x more likely to cause anaphylaxis than alternatives, but is given much less frequently
    • There is a tragic irony to the fact that patients with spurious penicillin allergies are often given teicoplanin perioperatively i.e. a significantly more anaphylactogenic drug

Neuromuscular blocking agents (33%)

  • The quaternary ammonium group is an antigen found in many drugs, foods, cosmetics and hair products, as well as NMBA
  • As such, prior exposure to NMBAs is not a prerequisite for NMBA-induced anaphylaxis
  • Rocuronium is the most common source of NMBA-anaphylaxis (NAP 6; incidence 8 in 100,000), although suxamethonium may also be implicated
  • Atracurium and mivacurium may cause non-anaphylaxis allergic reactions by causing direct release of histamine from mast cells

Other drugs

  • Chlorhexidine (9%)
  • Patent blue dye (5%)
  • Sodium thiopental
  • Colloids

  • Latex
    • Changes in policy have reduce incidence of latex anaphylaxis
    • There is an increased risk of latex allergy in healthcare workers, those undergoing repeated surgeries and those with tropical fruit allergy (kiwi, avocado, banana)
    • NB tracheal tubes do not contain latex and therefore do not increase risk
    • The exact reaction to latex depends on the route of exposure, previous exposure and predisposition (e.g. atopic individuals, food allergies)
      • Type 1 hypersensitivity reactions are most severe but least frequent, and there may be cross-reactivity with latex proteins in fruits e.g. banana, chestnut, avocado
      • Contact dermatitis due to cutaneous exposure, which is a T-cell mediated delayed hypersensitivity reaction
      • Non-immune mediated dermatitis is the commonest reaction, leading to itching, irritation and blistering

Opioids

  • Anaphylaxis to opioids is very rare
  • Morphine, diamorphine and codeine can cause direct mast cell degranulation and histamine release, without IgE antibodies
    • This means they can induced positive skin prick results in normal controls
    • Skin prick testing is not appropriate; drug provocation testing should used instead

  • Synthetic opioids (fentanyl, remifentanil alfentanil) do not induce histamine release
  • Skin prick and intradermal testing is therefore appropriate

  1. Angioedema of the face, lips and oropharynx that may precipitate airway obstruction
    • May necessitate intubation in the un-intubated patient

  2. Wheezing and bronchospasm (18%)
    • A more common presenting feature in asthmatics or the obese/overweight patient
    • Rising airway pressures and difficult ventilation
    • Absent capnograph trace (30%)
    • Pulmonary oedema may compound hypoxia

  3. Hypotension is the most common presenting complaint (46%)
    • All cases experience hypotension at some point (NAP6)
    • Hypotension is often refractory and may lead to circulatory collapse
    • 15% experience cardiac arrest
    • Tachycardia is often present too

  4. (No overt signs)

  5. Flushing, wheals or urticaria are an uncommon presenting symptom, are often a late sign and their absence does not exclude anaphylaxis

Differential diagnosis

  • Anaphylactoid or angiodeomatous reaction
  • Bronchospasm
  • Massive PE
  • High regional block
  • Haemorrhage
  • Myocardial infarction
  • Sepsis
  • Malignant hyperpyrexia
  • Tension pneumothorax

Immediate management

  • Should one be faced with a viva question on anaphylaxis, simply recite the opening gambit for any clinical emergency:
  • Anaphylaxis is an anaesthetic emergency and I would seek senior anaesthetic support as well as making a rapid but thorough assessment of the patient

  • One should then stop injecting or infusing the responsible agent and reach for the theatre action card, if available
  • The subsequent ABC approach should be familiar:
  1.  Maintain and, if necessary, secure the airway via endotracheal intubation

  2.  Administer 100% oxygen and ensure adequate ventilation (which may be tricky in the face of overwhelming bronchospasm)

  3.  Administer adrenaline, either 500μg IM (0.5ml 1:1,000) or 50μg IV (0.5ml of 1:10,000)
    • Paediatric dosing of adrenaline is 10μg/kg IV (0.1ml/kg 1:10,000 IV)
    • Repeat IV dose every 1 minute until circulation restored
    • Start an adrenaline infusion after three boluses [NB this differs from the 'infusion after two IM doses' recommended by the Resus Council]
    • Administer IV crystalloid bolus 20ml/kg to increase circulating volume
    • Passive leg raise to increase central blood volume
    • Start CPR if SBP ≤50mmHg

Early management

  • Consider adjunctive therapy:
    • Anti-histamines e.g. chlorphenamine 10mg IV
    • Steroids e.g. hydrocortisone 200mg IV
    • Bronchodilators such as aminophylline, magnesium or salbutamol
    • Bicarbonate if profound acidosis e.g. 50 - 100ml 8.4% NaHCO3
    • Additional vasopressors e.g. noradrenaline

  • Take blood for serum tryptase at 0, 1 - 2 and 24hrs
  • Discuss with senior anaesthetist and surgeon need to continue with surgery
  • Admit to ICU and consider leaving intubated if airway concerns, with an appropriate check for cuff leak prior to extubation
  • Use of a clinical scoring system to predict whether a true anaphylaxis is occurring (BJA, 2022) is of debateable use in my opinion

Subsequent management

  • Document events in patient notes and document allergy on drug chart
  • Inform patient of events and answer any questions
  • Write a letter to the GP informing them of the events
  • Inform the MHRA e.g. complete yellow card (in back of BNF)
  • Complete a critical incident form
  • Referral to immunology for allergen testing as per local/national guidelines

Mast cell tryptase

  • This is a neutral serine protease released from both mast cells and basophils
  • It is spontaneously released in pro-enzyme forms in a constitutive fashion and is a relatively stable molecule with a t1/2 of 2hrs
  • Hence, multiple measurements are needed to show a rise and then fall in suspected anaphylaxis
  • It may be raised outwith anaphylaxis in mastocytosis, AML and myelodysplastic syndromes

  • Mortality from perioperative anaphylaxis is fairly low;
    • The overall rate in NAP6 was 0.0003%
    • If the patient had life-threatening anaphylaxis, the rate was 3.8%
  • This is similar to the pre-NAP6 literature, which reported a rate of 1 - 4%, although higher than the 2% of an American patient cohort (BJA, 2021)
  • Most cardiac arrests in NAP6 were PEA

Risk factors for fatal anaphylaxis

  • Age >66yrs
  • Obesity
  • Existing coronary artery disease or, indeed, virtually any major medical comorbidity
  • Taking a beta-blocker or ACE-inhibtor, presumably by exacerbating hypotension or making it refractory
  • Undergoing cardiac surgery