This is a presentation on anaphylaxis by Michael Rose. Michael is an anaesthetist in Sydney and a leading expert in the world of anaphylaxis. He talks about the basics and recent developments in this field - an area of critical care relevant to us all.
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Michael rose on anaphylaxis
1. Dr Michael Rose
Director, RNSH AnaestheticAllergy Service
Chair,Australian and New Zealand AnaestheticAllergy Group (ANZAAG)
Chair,ANZCA AnaestheticAllergy Subcommittee
Member,Australasian Society of Clinical Immunology and Allergy
(ASCIA)
rnsaac@gmail.com
Anaesthetic anaphylaxis
July 2013
3. Once upon a time….
Elective anaesthesia was dangerous…..
Death/ morbidity due to :
Older drugs
Less emphasis on surgical anaesthetic audit / CPD
Lack of patient workup/information
Poorer monitoring
Airway emergencies
Anaphylaxis
MH
Now, otherwise healthy patients “expect” to make it through
without problems
4. Anaesthetic emergencies
Now….Anaphylaxis one of the most prominent causes of
unanticipated sudden catastrophe
Incidence of :
MH: 1:50,000 -1:100,000
CICO: 1:12,500 - 1:50,000
Anaphylaxis under anaesthesia: 1: 4,500 -1:10,000
5. What is
anaphylaxis ?
Anaphylactic vs. anaphylactoid now obsolete terminology
Clinical anaphylaxis - the presence of the following
Skin or mucosal changes – rash (erythema/urticaria) , peau d’orange,
angioedema
Plus one of…
Cardiovascular instability (hypotension, variable HR changes)
Respiratory insufficiency – bronchospasm, low sats
GIT issues – pain, vomiting, diarrhoea
Sampson HA, Muñoz-Furlong A, Campbell RL, Adkinson NF et al. Second symposium on the definition and management of anaphylaxis: Summary report—Second National
Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium. J Allergy and Clin Immunol 2006 ;117(2): 391-397
6. Severity Grading
1. Cutaneous Signs
2. Moderate multi-organ involvement
Includes hypotension, severe tachycardia, bronchial hyper-
reactivity
3. Severe multi-organ involvement
Includes severe bronchospasm, arrhythmias, cardiovascular
collapse
4. Cardiac and or respiratory arrest
5. Death (bad, lots of paperwork)
7. What makes anaesthetic anaphylaxis
different from food anaphylaxis ?
Often sudden onset and severe
IV administration of antigen generally (except chlorhex/dyes/latex)
Often other things occurring that may mimic anaphylaxis
Insufflation of peritoneum
Cardiac ischaemia
Haemorrhage
Intubation (bronchospasm)
Skin reaction often not seen at time or at all
Gastrointestinal symptoms not prominent/noticed
11. What do we do?
History:
of event from notes/anaesthetist/patient
Results of already conducted investigations (e.g. MCT, sIgE)
Skin testing
Intradermal (standard +/- stronger “validated” concentrations)
Skin Prick
Serum tests
Baseline MCT
SIgEs (“RASTs”)
Morphine/pholcodine for NMBAs
Chlorhexidine
Latex
Antibiotics
IV Challenge
The 1st
year registrar 2am test….
12.
13. Red flags of difficult cases
Poor information / documentation
Not referred directly from the anaesthetist involved
Vague descriptions of events (mild hypotension, possible rash)
No MCTS
High normal or completely normal MCTs with a good clinical
picture
Severe atopy and dermatographism
14. Causes – RNSAAC 2007-2013
1. NMBAs
2. Antibiotics
3. Chlorhexidine
4. Colloid
5. Patent Blue
6. (Local Anaesthetics – often type 4 hypersensitivity)
15. Muscle relaxant Cross-reactivity
Probably around 60% have at least one other NMBD
cross-reacting
Some have multiple
Not entirely predicable by class/structure
Do not substitute without testing results!!
23. Mast cell tryptases
• Samples:
• First sample when situation under control (ideal 60 mins)
• 2nd sample 4 hours
• 3rd
sample 24 hours or later
• The ‘delta’ tryptase from peak to baseline often most informative
• Serum tube 5-10mls, labeled with time of sample
• Cooled to 4 degrees if delay / transport
• Post mortem samples can be useful in sudden unexplained
death
26. Australia
No central database, but many reports of increasing incidence
NZ
Some centres report their cases of allergy to a central body, the
Centre for Adverse Reactions Monitoring (CARM)
In the 43 years from 1965 until April 2008, CARM had 54
reports of chlorhexidine reactions.
Four years later, by April 2012, these numbers had almost
doubled to 100 reports
The Problem
27. Latex allergy –
Widespread in hospital products
Not just perioperative
Often delayed onset of reaction
Concern after reactions increased after widespread use of latex
products occurred
Less of an issue now with labeling and alternatives
Sound Familiar?
28. Blood collectors
Radiology procedures
ICU
Emergency department
General ward staff
The solution requires…
31. Widespread use of chlorhexidine as an antiseptic
Clearly an effective antiseptic
Broad spectrum
Persistent effect in skin
“One size fits all” approach
Controversies
33. Texas Childrens Hospital
2004 – Chlorhexidine routinely used on CVC dressing changes
2005 – Chlorhexidine mouthwashes daily for AML patients
qacA/B gene emerged in 2006
10% of MRSA 2009
22% of MRSA 2011
Resistance
34. Japan
Issued a prohibition of chlorhexidine use on mucosal
membranes in 1984
USA
FDA issued a warning about increasing incidence of allergy
from impregnated CVCs and other products in 1998
Warnings
35.
36. Moves by health departments toward recommending
chlorhexidine for all procedures
Good evidence for effectiveness of chlorhexidine on long
duration lines (CVCs)
No good evidence of benefit for short duration peripheral access
Chlorhexidine baths pre-op?
Chlorhexidine policy
37. Chlorhexidine anaphylaxis is
increasing
Be prepared to treat
chlorhexidine allergic patients
Be extra vigilant dealing with
known chlorhexidine allergy
patients
Risk versus benefit
Still remains the most effective
antiseptic
Rethink use of chlorhexidine for
low infection risk
Develop a chlorhexidine – free
38. Case discussions
• 24yr male
• Anaphylaxis under anaesthesia for
fundoplication
• Cardiac arrest, rash, angioedema
• Treated promptly with adrenaline (bolus
and infusion) and IV fluid
• MCT 126mcg/L
39. Case 1 continued
• Skin tested -
Positive to Rocuronium
Cross reactive to
• Suxamethonium
• Cisatracurium
• Pancuronium
Negative to Vecuronium
Subsequent safe anaesthesia with
same induction drugs and
vecuronium
40. Case 2
25 year old male
Metastatic bowel cancer
Has hemicolectomy and chemotherapy to reduce peritoneal
and hepatic disease
Port inserted for chemo
41. Case 2 continued
During chemo
Multiple episodes of minor anaphylaxis from swabbing over
port site before accessing
One episode of anaphylaxis after an infusion line was swabbed
before piggy-backing a chemo solution
……….Unrecognised
42. Then…
GA for peritonectomy/liver resection
Massive anaphylaxis after a chlorhexidine coated CVC is
inserted through chlorhexidine/alcohol prep
Cardiac arrest
Resuscitated
Subsequently tested positive to chlorhexidine on
intradermal, skin prick and sIgE tests
43. Subsequently
Meeting involving theatres, radiology, ICU about how to
manage this patient and his multiple investigations without
exposure to chlorhexidine
Chlorhexidine - free protocol developed
44. Case 3
42 yr male
Percutaneous lithotripsy
Anaphylaxis post induction –
fentanyl/propofol/Keflin/clonidine/dexamethasone
Hypotension to 60mmHg plus rash
Required 500mcg total IV dose of adrenaline
Single MCT done intraoperatively (? Time)
elevated (15.9 mcg/ml)
Postop-course complicated by bleeding. Given cephalexin as part of
treatment – caused severe red itchy rash
Intradermal testing at normal/higher concentrations negative
to all, including cephalothin
45. Case 3 cont.
Represented for testing on a second occasion.
Still negative to all tested meds
But
What if Keflin (cephalothin) was actually cephazolin??
Tested positive intradermally and SPT to cephazolin