1. Anaphlaxis
Dr Ferdi Menda

2. 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.

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

4. 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.

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

6. 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.

7. Uniphasic Anaphylaxis
Treatment
Initial Symptoms
Time
Antigen Exposure

8. 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

9. Protracted Anaphylaxis
Initial Symptoms
Time
Possibly >24 hours
Antigen Exposure

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

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

12. 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 !!

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

14. 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.

15. SKIN
Erythema
Urticaria
Edema

16. UPPER AIRWAY
Stridor
Hoarseness
Angioedema
Sneezing

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

18. Cardiovascular symptoms
arrhythmias

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

20. 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 ?

21. Anaphylaxis therapy* STOP the responsible agent Call for HELP
Warn the SURGEON
Trandelenburg position
Ventilation+%100 O2
Fluid therapy:
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 ERC 2010.

22. 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
mg iv
mg im
Mild rxn: micg iv
* Kroigaard M. Scandinavian Clinical Practice Guidelines on the diagnosis, management and follow-up o anaphylaxis during anaeshesia. Acta Anaesthesiol Scand 2007.

23. 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: micg titrate,
PEDIATRIC: 1 micg/kg.
* ERC anaphylaxis guidelines 2010.

24. 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.

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

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

27. Anaphylaxis: Unresponsive to Adrenaline !
NORADRENALIN: 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).

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

30. 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.

31. 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.

32. 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.

33. Primary evaluation Serum triptase & IgE Ab.
Blood sample for analysis must be drawn within 1-4 hrs following the rxn 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.

34. 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.

35. Frequently used agents during Anesthesia
NMBA. (skin prick test “gold standart”)
1/ (france,norway,GB).
Other countries 1/ /
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%)

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

37. WARN the patient
Bracelet
Detailed epicrisis