This document discusses perioperative anaphylaxis. It provides information on the epidemiology, including incidence rates that vary between countries. Common causal agents are noted to be neuromuscular blocking agents, latex, and antibiotics. The document outlines steps for investigating a suspected case of perioperative anaphylaxis, including measuring serum tryptase levels and doing skin or blood tests to identify sensitizing agents. Factors affecting the rapidity of symptom onset after exposure are also discussed. Treatment options are mentioned but not described in detail.

1. PerioperativePerioperativePerioperativePerioperativePerioperativePerioperativePerioperativePerioperative
AnaphylaxisAnaphylaxisAnaphylaxisAnaphylaxisAnaphylaxisAnaphylaxisAnaphylaxisAnaphylaxisAnaphylaxisAnaphylaxisAnaphylaxisAnaphylaxisAnaphylaxisAnaphylaxisAnaphylaxisAnaphylaxis
CHULEEPORN KONGMEESOOK, M.D.CHULEEPORN KONGMEESOOK, M.D.CHULEEPORN KONGMEESOOK, M.D.CHULEEPORN KONGMEESOOK, M.D.CHULEEPORN KONGMEESOOK, M.D.CHULEEPORN KONGMEESOOK, M.D.CHULEEPORN KONGMEESOOK, M.D.CHULEEPORN KONGMEESOOK, M.D.

2. OutlineOutline
•• EpidemiologyEpidemiology
•• Causal agentsCausal agents
•• InvestigationInvestigation•• InvestigationInvestigation
•• ManagementManagement

3. EpidemiologyEpidemiology
•• Other countries varies widelyOther countries varies widely
1/1,7001/1,700 -- 1/20,0001/20,000
•• In France 1/13,000In France 1/13,000
•• In Australia 1/10,000In Australia 1/10,000 -- 1/20,0001/20,000
•• MortalityMortality rate 5rate 5--7%7%
A.V.A.V. MichavilaMichavila Gomez et alGomez et al AllergolAllergol ImmunopatholImmunopathol 20132013;; 11--1212 ((article in pressarticle in press))
PMPM MertesMertes, et al, et al J Investig Allergol Clin ImmunolJ Investig Allergol Clin Immunol 20112011;; 2121((66) :) : 442442--453453
P. W. Ewan et al Clinical & Experimental AllergyP. W. Ewan et al Clinical & Experimental Allergy 20102010;; 4040 :: 1515––3131
Middleton'sMiddleton's allergy:principlesallergy:principles and practiceand practice 88thth editionedition

4. Epidemiology in ThailandEpidemiology in Thailand
•• PerioperativePerioperative allergic reactions 1/5,500allergic reactions 1/5,500
SomboonSomboon ThienthongThienthong et al J Med Assoc Thai 2005; 88 (7) : 128et al J Med Assoc Thai 2005; 88 (7) : 128--3333

5. Paul MichelPaul Michel MertesMertes et alet al J Allergy Clin Immunol 2011; 128 : 366J Allergy Clin Immunol 2011; 128 : 366--7373

6. SomboonSomboon ThienthongThienthong et al J Med Assoc Thai 2005; 88 (7) : 128et al J Med Assoc Thai 2005; 88 (7) : 128--3333

7. Paul MichelPaul Michel MertesMertes et al Anesthesiology 2003; 99:536et al Anesthesiology 2003; 99:536––4545

8. Paul MichelPaul Michel MertesMertes et alet al J Allergy Clin Immunol 2011;128:366J Allergy Clin Immunol 2011;128:366--7373

9. HistoryHistory
•• EExxtteenntt ooff ssiiggnsns
•• DrDruuggss aanndd rreellaatteedd ccoommpopouunnddss
•• TiTimmee eellaappsedsed bbeettweenween adadmmiinniissttrarattiioonn
aanndd ononsetset ooff ssyymmppttoomsms
•• PPrerevviioouuss aalllleerrggiieses ffrroomm ddrruuggss oorr rerellaatteded
ccoommpopouunndsds
•• UUnnddererllyyiinngg ccoonnddiittiiononss
D. G.D. G. EboEbo et al Allergy 2007;62: 471et al Allergy 2007;62: 471––487487

10. EExxtteenntt ooff ssiiggnsns
•• Most case ofMost case of perioperativeperioperative anaphylaxisanaphylaxis
characterized by severe respiratory andcharacterized by severe respiratory and
cardiovascular manifestationscardiovascular manifestations
D. G.D. G. EboEbo et al Allergy 2007;62: 471et al Allergy 2007;62: 471––487487

11. Paul MichelPaul Michel MertesMertes Anesthesiology 2003; 99:536Anesthesiology 2003; 99:536––4545

12. PMPM MertesMertes et alet al J Investig Allergol Clin Immunol 2011; 21(6): 442J Investig Allergol Clin Immunol 2011; 21(6): 442--453453

13. Paul MichelPaul Michel MertesMertes AnesthesiologyAnesthesiology 20032003;; 9999::536536––4545

14. •• Most common are NMBAs, latex andMost common are NMBAs, latex and
antibioticsantibiotics
DrDruuggss aanndd rreellaatteedd ccoommpopouunnddss
D. G.D. G. EboEbo et al Allergy 2007;62: 471et al Allergy 2007;62: 471––487487

15. D. G.D. G. EboEbo et al Allergy 2007;62: 471et al Allergy 2007;62: 471––487487

16. •• Clinical signs and symptoms usually startClinical signs and symptoms usually start
within 5within 5––10 min after administration but10 min after administration but
can occur within secondcan occur within second
TiTimmee eellaappsedsed bbeettweenween adadmmiinniissttrarattiioonn
aanndd ononsetset ooff ssyymmppttoomsms
•• Natural rubber latex (NRL) and antisepticsNatural rubber latex (NRL) and antiseptics
delayed onset and occurs duringdelayed onset and occurs during
maintenancemaintenance anaesthesiaanaesthesia or recoveryor recovery
D. G.D. G. EboEbo et al Allergy 2007;62: 471et al Allergy 2007;62: 471––487487

17. P. W. Ewan et al Clinical & Experimental Allergy 2010; 40 : 15P. W. Ewan et al Clinical & Experimental Allergy 2010; 40 : 15––3131

18. •• CCareareffuull rreettrroossppectectiivvee assessmassessmeenntt ooff
mmeeddiicalcal hhiissttooryry aanndd rreeccoordsrds
•• IIddeennttiifyfy rriisksk ooff ppaattiieennttss dduurriinngg
PPrerevviioouuss aalllleerrggiieses ffrroomm ddrruuggss oorr
rerellaatted ced coommpopouunndsds
•• IIddeennttiifyfy rriisksk ooff ppaattiieennttss dduurriinngg
pprereananesestthheetiticc vviissiitt
D. G.D. G. EboEbo et al Allergy 2007;62: 471et al Allergy 2007;62: 471––487487

19. •• IdentIdentiiffiication of ucation of unnddererllyyiinngg ccoonnddiittiioonsns
hheellpp ttoo iiddeenntitiffyy ccaauusasattiivvee ccompompooununddss
•• AAttooppiicc rriisksk forfor aannaapphhyyllaaxxiis fs frroomm NNRRLL
UUnnddererllyyiinngg ccoonnddiittiiononss
•• AAttooppiicc rriisksk forfor aannaapphhyyllaaxxiis fs frroomm NNRRLL
D. G.D. G. EboEbo et al Allergyet al Allergy 20072007;;6262:: 471471––487487

20. Paul MichelPaul Michel MertesMertes Anesthesiology 2003; 99:536Anesthesiology 2003; 99:536––4545

21. Paul MichelPaul Michel MertesMertes Anesthesiology 2003; 99:536Anesthesiology 2003; 99:536––4545

22. InvestigationInvestigation
•• SerumSerum tryptasetryptase
•• Skin testSkin test
•• Serum specificSerum specific IgEIgE antibodiesantibodies•• Serum specificSerum specific IgEIgE antibodiesantibodies
•• Other tests :Other tests : BasophilBasophil activation testactivation test
P. W. Ewan et al Clinical & Experimental Allergy 2010; 40 : 15P. W. Ewan et al Clinical & Experimental Allergy 2010; 40 : 15––3131

23. SerumSerum tryptasetryptase
•• Recommended 60Recommended 60––120 min after onset of120 min after onset of
symptomssymptoms
•• Tryptase’sTryptase’s halfhalf--life about 120 minlife about 120 min
•• New sample should collect >2 days afterNew sample should collect >2 days after
reaction for comparison with baselinereaction for comparison with baseline
levelslevels
D. G.D. G. EboEbo et al Allergy 2007;62: 471et al Allergy 2007;62: 471––487487

24. D. G.D. G. EboEbo et al Allergy 2007;62: 471et al Allergy 2007;62: 471––487487

25. P. W. Ewan et al Clinical & Experimental Allergy 2010; 40 : 15P. W. Ewan et al Clinical & Experimental Allergy 2010; 40 : 15––3131

26. P. W. Ewan et al Clinical & Experimental Allergy 2010; 40 : 15P. W. Ewan et al Clinical & Experimental Allergy 2010; 40 : 15––3131

27. TreatmentTreatment
David L.David L. HepnerHepner et alet al AnesthAnesth AnalgAnalg 2003;97:13812003;97:1381––9595

28. THANK YOUTHANK YOUTHANK YOUTHANK YOUTHANK YOUTHANK YOUTHANK YOUTHANK YOU

29. Paul MichelPaul Michel MertesMertes AnesthesiologyAnesthesiology 20032003;; 9999::536536––4545