Prof. mridul Panditrao explains his ideas about the anaphylactic reactions in the peri-operative( pre, intra and post) period, how to diagnose them, treat them and also to prevent them.

1. PERIOPERATIVE MANAGEMENT
OF
ANAPHYLACTIC REACTIONS

2. PROF. MRIDUL M. PANDITRAO
CONSULTANT
DEPARTMENT OF ANESTHESIOLOGY AND
CRITICAL CARE
RAND MEMORIAL HOSPITAL
FREEPORT
GRAND BAHAMA
THE COMMONWEALTH OF BAHAMAS

3. 1. Importance of Diagnosis.
2. Goals of Diagnosis
3. Risk factors in patients.
4. Suppression of Mediators Release.
5. Tests to be done at the time of
reaction.
6. Tests to be done 4-6 weeks after
reaction.
7. Documentation & Medico legal
Implications.
8. Pre anesthetic testing.

4. IMPORTANCE OF DIAGNOSIS
1. Epidemiological.
2. Medico legal.
3. To prevent reactions in subsequent
anesthetics.

5. GOALS OF DIAGNOSTIC TESTING
1.Cause of reaction.
2. To pinpoint a specific drug.
3. Which other drug could produce similar
reaction.

6. RISK FACTORS IN PATIENTS
1. Rare in neonates and Geriatrics
2. Rare in Shock states
3.Behavioral changes in mast cells
4. Low levels of Renin Angiotensin systems
5. Relation with h/o Atopy or Allergy

7. RISK FACTORS IN PATIENTS (CONTD)
6. Female : Male – 4:1
↑ IgA, IgM, IgG → Polio virus & bovine albumine
Female Sex hormones- Prolactin ↑ses Cell
mediated responses
Androgenic hormones- Immunosuppressive
7. Previous exposure- not important
8. β blocked patients – Difficult to treat
Needs ↑ doses

8. SUPPRESSION OF MEDIATOR RELEASE
1. Adenyl cyclase- ↑ cAMP synthesis →↓ mast cell
degranulation. Prostaglandins, histamine ( small
doses ) & β agonists ↑ adenyl cyclase. Epinephrine
acts via β receptors.
2. Corticosteroids act → cytokines →↓ mast cell activity.
3. Phosphodiesterase inhibitors→ ↑cAMP by
inhibiting its breakdown.
4. Disodium cromoglycate inhibits
Ca influx into cell & prevents initiation of response.

9. TESTS PERFORMED DURING REACTION
1.Plasma histamine: 0-1ng/ml. Half life is only 10 minutes.
Level > 20ng/ml shows histamine involved reaction.
2. Urinary Methyl Histamine : 0-118mcg/24hours sample
10 in 10 patients →↑ plasma histamine.
4 in 10 patients →↑ urinary methyl histamine.
3. Immunoglobulin E levels-↑ indicates reaction.
* Drug specific IgE.
4. Complement levels is serum : 55-110ng/ml.
5. Mast Cell Tryptase- 10ng/ml (2-23ng/ml).
25% of Mast Cell protein- degranulation – liberated.
Half life- 90 min. 1 hrs, 6 hrs & 24 hrs- sensitive test.

10. TESTS DONE 4-6 WEEKS AFTER THE REACTION
 Time allowed to normalize.
 All drugs used should be tested.
 Patient to be made aware.

11. SKIN TESTING
 Main stay in our hands as labs are distant.
 Skin of back and anterior face of forearm.
 ho anaphylaxis- positive for plasma
H, Tryptase, Urinary Methyl H.
 Operation Theatre Complex- Resuscitation
measures , Drugs, IV fluids, Equipment.
 Monitors – pulse, BP, resp,
O2 saturation.
 Sweating /discomfort.

12. CONTD.
 0.4% phenol in saline- negative - < 2-4mm dia
 9% codeine phosphate- positive- > 15mm dia
 Drug test positive- wheal > 7-8mm dia
 Each prick test – observed 15 minutes .
 Next drug- 30 mins after previous.
 2 drugs on each forearm/ day.
 Injection site examined 12-24 hrs- late reaction.
 Not useful for colloids & contrast media.
 Cross sensitivity should also be tested.

13. 2 TYPES OF SKIN TESTING
 Intra dermal injection-1 in 100 con of drug
used - flare or wheal. If negative- Less
dilutions may be tried in strongly suggestive
case with caution.
 Prick test- drop of undiluted drug placed on
forearm- prick with sterile needle through
drop.
 Moderate to severe reactions-seen & treated.

14. RADIO IMMUNO ASSAY
 Reflects IgE bound to mast cells.
 Antigen ( drug) + patient’s serum –
incubated- antigen antibody complex
formed.
 Complex + radio labeled anti IgE –
incubated bound radioactivity assessed.

15. SKIN TEST+ RIA- CONCLUSIONS
 ST more specific than RIA- particular drug.
 Drug specific RIA – not available for all
drugs.
 ST+RIA- preferable.
 Cross sensitivity – better with RIA.
Thio and NMBD.
LEUCOCYTE & BASOPHIL- H - not specific.

16. MEDICO LEGAL IMPLICATIONS
CLEAR DUTIES
1. Diagnose & treat.
2. Investigations in immediate, postop 4-6
weeks as per availability.
3. Skin testing – 4-6 weeks. All drugs and
cross.
4. Documentation: all events – intra - post –
late post op on case paper& main hospital
records.
5. Communicate results to patients and

17. SUBSEQUENT ANAESTHESIA
• After listening to these tests - All patients- skin test &
RIA.
• No predictive value. Not practical.
PRE-ANAESTHETIC TESTING:
• Done in patients with positive H/O reaction during
anaesthesia or any treatment.
• Possible in elective- but not in emergency.
• Testing schedule:
 History, previous records – study & document.
 Skin testing planned – all precautions . All drugs to be
used, cross sensitivity.
 All testing negative – does not rule out possibility. All
precautions & resuscitative measures -ready.

18. PREFERENCES
• Premedication- fentanyl, pethidine over
morphine.
• Induction- ketamine/ propofol /thiopentone.
• Inhalational anaesthesia preferred over TIVA.
• Regional anaesthesia- lesser no. of drugs, less
sensitivity to local anaesthetic.
• Prefer Starches over Haemacoel.
• Preventive measures – corticosteroids,
disodium cromoglycate, β agonists, epinephrine.

19. EMERGENCY CASES
 No time for testing.
 If previous records available – avoid those
drugs
 other preferences as per the routine cases.
 ketamine / propofol / thiopentone
 Mivacurium / pancuronium / vecuronium
 Inhalational better than TIVA.
 Regional anaesthesia better than general
anaesthesia.

20. Thank You

21. FUTURE DEVELOPMENTS
• Rare event so simulated anaphylaxis drill – practical
• Desensitization by exposure to increasing doses still
inconclusive.
• More efficient H receptor blockers & other mediator
blockers.
• Safer drug designing eliminating anaphylaxis
component.
• Methods to measure trigeriness of mast cell.
• Measurement of circulating IL-4,5, still distant
possibility.