Anaphlaxis Dr Ferdi Menda

Anaphylaxis A severe life threatening (Type I) immediate hypersensitivity reaction. The reaction occurs when the person reexposed to an ‘allergen’, which leads to IgE Ab during previous exposure.

Anaphylaxis Injected, inhaled or ingested substance –usually drugs, food, insect venom- can serve as the allergen itself.

Anaphylaxis During 1st exposure, mast cells (A)-allergen (B) complex secrete IgE (C) antibodies. Some of these IgE remain attached to the mast cells. During the 2nd exposure allergen combines with IgE on the surface of the cell & release inflammatory mediators.

Anaphylaxis Allergen: IgE + Ag Mast cells, basophils: Histamin, triptase, leukotriens, eosinophilic chemotactic factors are released. IgG leads to “complemant” system activation.

Anaphylaxis Non-Allergic (non-IgE, non-immun): Reaction is developed by means of direct pharmacologic, toxic stimulus of the mast cells & basophils; Inflammatory mediators are released.

Uniphasic Anaphylaxis Treatment Initial Symptoms Time Antigen Exposure

Second-Phase Symptoms Biphasic Anaphylaxis Treatment Treatment 1-8 hours Second-Phase Symptoms Initial Symptoms Classic Model Time 1-72 hours New Evidence Antigen Exposure

Protracted Anaphylaxis Initial Symptoms Time Possibly >24 hours Antigen Exposure

Anaphylactoid reaction An identical or very similar clinical response (skin reaction) which is not mediated by IgE, or an Antigen-Antibody process.

Anaphylaxis during Anesthesia Anaphylaxis incidence during anesthesia is: 1/5.000-1/20.000 Multiple drug use duing general anesthesia may mask the symptoms. Diagnosis during anesthesia is DIFFICULT !

Agents responsible for anaphylaxis during Anesthesia Non-depolarizing neuromuscular blockers Latex & antibiotics Colloid solutions, barbituric acid All drugs & agents used during surgery or anesthesia may be responsible Mind the solutions or drugs used by the SURGEON !!

Cerrahın kullandıklarına DİKKAT !! Topical, infiltration Local Anesthetic agents (<%1 anaphylaxis) Irrigation solutions Latex Disinfectant Markers (patent blue)

Increased peristaltism tachycardia, arrhytmia, Mast cell activation, degranulation GIS Respiratory system Airway CVS SKIN Increased peristaltism Nausea, vomiting Bronchospasm, Upper airway edema Hypotension, tachycardia, arrhytmia, collaps Erythema Urticaria Edema HYPOVOLEMIA; Deep general anesthesia; Deep regional anesthesia may mask the symptoms.

SKIN Erythema Urticaria Edema

UPPER AIRWAY Stridor Hoarseness Angioedema Sneezing

Respiratory system Wheezing Dyspnea Normal Airway Airway inflammation Bronchospasm & mucus production

Cardiovascular symptoms arrhythmias

Gastrointestinal symptoms Nausea, vomiting, Diarrhea, Abdominal cramp like pain: uncommon except with food allergies.

Anaphylaxis: Generally occurs immediately after drug injection (2-15 mins). Generally related to iv agents. Rarely occurs 2.5 hour after the drug therapy. No death reports > 6 hours after the reaction. Reaction time following oral drug intake is unpredictable ?

Anaphylaxis therapy* STOP the responsible agent Call for HELP Warn the SURGEON Trandelenburg position Ventilation+%100 O2 Fluid therapy: 500-1000 mL iv adult, ≥20 mL/kg çocuk (%09 NaCl, RL) * Kroigaard M. Scandinavian Clinical Practice Guidelines on the diagnosis, management and follow-up o anaphylaxis during anaeshesia. Acta Anaesthesiol Scand 2007 + ERC 2010.

Anaphylaxis therapy: ADRENALIN* PEDIATRIC Severe anaphylaxis 0.01 mg/kg iv 5-10 micg/kg im Mild rxn: 1-5 micg/kg iv ADULT: Severe anaphylaxis 0.1-1 mg iv 0.5-0.8 mg im Mild rxn: 10-50 micg iv * Kroigaard M. Scandinavian Clinical Practice Guidelines on the diagnosis, management and follow-up o anaphylaxis during anaeshesia. Acta Anaesthesiol Scand 2007.

Anaphylaxis therapy: ADRENALIN* >12 y/o & adult 0.5 mg IM 6–12 y/o 0.3 mg IM <6 mo–6 y/o 0.15 mg IM IV ADRENALIN: ADULT: 50 micg titrate, PEDIATRIC: 1 micg/kg. * ERC anaphylaxis guidelines 2010.

Epinephrine Injection: IM vs. SQ Simons et al:Prospective, randomized, blinded study in children T-max was 8 ± 2 minutes after injection of epinephrine 0.3 mg from an EpiPen IM in the vastus lateralis vs. 34±14 minutes (range, 5 to 120) after injection of epinephrine 0.01 mg/kg SQ in the deltoid region.

Epinephrine Absorption: SQ vs. IM Simons FER et al. J Allergy Clin Immunol 1998;101:33-7.

Anaphylaxis: Segondary therapy ? CORTICOSTEROID Adult HIDROCORTISON 250 mg, M.Prednisolon 80 mg iv Pediatric HIDROCORTISON 50-100 mg, M.Prednisolon 2 mg/kg iv Antihistaminic: Adult Promethazin 50 mg iv Pediatric Promethazin 0.3-1 mg/kg iv/im Bronchospasm: nebulised β2-agonist. Not a 1st choice therapy.

Anaphylaxis: Unresponsive to Adrenaline ! NORADRENALIN: 0.05-0.1 mcg/kg/min VASOPRESSIN : 2-10 IU iv doses until response. GLUCAGON : 1-2 mg iv doses until response (in patients taking beta-blocker & unresponsive to high dose adrenaline).

Patients having anaphylactic rxn previously with Polen, animal fur, dust atopy Former prolonged latex exposure may develop reaction with LATEX.

RECOMMENDATIONS Anaphylaxis with Local Anesthetics is RARE; prefer Regional or local anesthesia. Agent of choice for General anesthesia is VOLATILE. “No Anaphylaxis is reported” AVOID Latex & Neuromusculer blockers ! Antihistaminic/steroid premedication will probably not prevent “anaphylactic shock” ? If known to cause a previous reaction, avoid using that drug/agent.

Follow-up After a moderate-severe anaphylactic rxn: Follow-up with blood (triptase), then skin test. Skin test: skin prick, intradermal test (IgE) or If there is a local or disseminated urticeria related to Chlorhexidin skin test is necessary. Follow-up is not necessary: Erhythema around the injection site, isolated bronchospasm in patients with previous bronchial reactivity.

When we decide an Alergy test, the following should be reported: Symptoms Severity of the reaction Onset time and length of the reaction, Therapy All the agents used before the reaction Anesthesia form, notes Fill the advers event form.

Primary evaluation Serum triptase & IgE Ab. Blood sample for analysis must be drawn within 1-4 hrs following the rxn. 5-10 mL blood, serum. The timing of the blood sampling after the reaction should be noted ? Control blood sample should be drawn before Anaphylaxis or 24 hrs after the reaction. Blood for IgE analysis can be sampled within 6 months after the reaction.

Secondary evaluation Skin test: Drug provacation test: RISKY ! Evaluates mast cell rxn by IgE. Salin (-) control, Histamin (+) control. Test has to be done 6 weeks after the reaction. Bir NMBA ile (+) sonuç alındıysa, diğer NMB test edilmeli. Bir LA rxn varsa diğerleri test edilmeli. Cross reactivity. Drug provacation test: RISKY ! It has to be performed after the skin test. Generally 1/10 of the therapeutic dose of the drug responsible for the reaction is given via same route.

Frequently used agents during Anesthesia NMBA. (skin prick test “gold standart”) 1/5.000-10.000 (france,norway,GB). Other countries 1/50.000-1/150.000. Latex (<5-17.7%) Antibiotics. (Penicillin 0.1%) 15% of all the Anaphylactic rxns Chlorhexidin. 12% of all the rxns during anesthesia are related to it (in denmark). Gelatin (4%-france). HES (0.006%)

Frequently used drugs during Anesthesia Ketamine, Midazolam. Very rare. Opioids. Low incidance. L.Anesthetics. Very low. Propofol. (2.3%) Rare. Thiopental. 1/23.000-29.000 (higher in female) NSAID. (general population 1%) rarely a problem during anesthesia. COX-2 inhibitors may be safer ?

WARN the patient Bracelet Detailed epicrisis