Anaesthetic allergy: Journals & articles

Abstract
Perioperative anaphylaxis is a potentially life-threatening emergency that requires prompt recognition and institution of life-saving therapy. The Australian and New Zealand College of Anaesthetists and Australian and New Zealand Anaesthetic Allergy Group have partnered to develop the anaphylaxis management guideline along with crisis management cards that are recommended for use in suspected anaphylaxis in the perioperative setting. This is the third version of these guidelines with the second version having been published in 2016. This article contains the revised Australian and New Zealand Anaesthetic Allergy Group/Australian and New Zealand College of Anaesthetists perioperative anaphylaxis management guideline, with a brief review of the current evidence for the management of anaphylaxis in the perioperative environment.

Sugammadex has been used for more than ten years in Australia and New Zealand and has been implicated as an effective treatment, and in some cases a potential cause, of a critical incident. We aimed to identify and analyse critical incidents involving sugammadex reported to webAIRS, a de-identified voluntary online critical incident reporting system in Australia and New Zealand. We identified 116 incidents where the reporter implicated sugammadex as either a cause (23 cases) or a treatment (93 cases) during anaesthesia. There were 17 incidents suggestive of sugammadex anaphylaxis, although not all were confirmed by skin testing. There were six incidents when bradycardia was temporally related to sugammadex administration, although it was not possible to exclude other causes or contributory factors. There were nine incidents in which sugammadex was used to reverse aminosteroid-related neuromuscular blockade successfully in a 'can't intubate, can't oxygenate' (CICO) situation, and a further 67 incidents in which sugammadex was used to reverse aminosteroid neuromuscular blockade as part of the management of other critical incidents. While sugammadex was used during the management of 16 cases of anaphylaxis, there was no clear indication that this altered the course of the anaphylaxis in any of the cases. These reports indicate that sugammadex can be a potential trigger for anaphylaxis and that its use may be associated with the development of significant bradycardia. However, it is not possible to estimate or even speculate on the incidence of these sugammadex-related incidents on the basis of voluntary reporting to a database such as webAIRS. The reports also indicate that sugammadex has been used successfully to reverse residual or deep aminosteroid neuromuscular blockade in critical incident situations and to help rescue CICO scenarios. These findings provide further support for ensuring the ready availability of sugammadex wherever aminosteroid muscle relaxants are used.

In this study, the published sugammadex-induced anaphylaxis reports were reviewed to determine similarities in their presentation during anesthesia. PubMed was searched for sugammadex-induced anaphylaxis without time limitation. Reports were evaluated if they were in English and met the criteria of anaphylaxis determined by the World Allergy Organization. Two independent reviewers extracted and assessed the data using predesigned data collection forms. In total, 23 suitable articles were found and 33 sugammadex-induced anaphylaxis cases were included in the study. The mean age was 43.09 years (from 3-89 years) and 17 (51.5%) of the patients were female. Considering all reported cases, the average onset time of anaphylaxis was 3.08 min, with a median of 3 min (range 1-8 min). The most common signs and symptoms were hypotension, tachycardia, erythema, and desaturation. Of the 20 patients who underwent confirmatory skin testing, 15 had a positive skin reaction for sugammadex. Epinephrine was not given when indicated in about 25% of cases. Sugammadex-induced anaphylaxis onset time was less than 5 min in 92.3% of all the reported cases. Rapid diagnosis and early recognition of signs and symptoms of anaphylaxis are essential for a favorable prognosis. Treatment needs to be started as soon as possible to ensure the best outcome for the patient.

An estimate of the incidence of perioperative
anaphylaxis is 1 in 4500–20 000, with mortality rates
as high as 6%. The current incidence of chlorhexidine anaphylaxis in the perioperative setting in Australia is unknown but is 9% in the United Kingdom and 9.6% in Denmark.

Abstract
Background: Perioperative anaphylaxis is a life-threatening clinical condition characterized by severe respiratory and cardiovascular manifestations. Neuromuscular blocking agents are the most common cause of anaphylaxis during anesthesia.

Case: We report a case of rocuronium-induced anaphylaxis treated with sugammadex. A 75-year-old female was scheduled to undergo spinal surgery. She had no history of allergies. After the injection of rocuronium, she developed hypotension and tachycardia, and skin rashes and urticaria appeared. The patient received sugammadex to delay the operation, and her vital signs were stabilized. On the 76th postoperative day, we performed intradermal tests for rocuronium, propofol, and cefazolin. Diluted rocuronium alone induced 14 mm of flare and 8 mm of wheal within 5 min, both of which disappeared within 15 min after the intradermal injection.

Conclusions: Sugammadex is a useful rocuronium antagonist that can be used to treat rocuronium-induced anaphylaxis.

Abstract
Background: Anaphylaxis to propofol is rare; however, providers face a clinical quandary as medication warnings still exist regarding propofol administration to egg-, soy-, and peanut-allergic patients.

Aims: The primary aim evaluated the rate of allergic reactions during propofol-containing anesthesia in patients listed allergic to egg, soy, or peanut compared with nonallergic patients who received propofol. The secondary aim evaluated the relationship between food allergy history and allergy testing data.

Methods: A retrospective chart review conducted between May 2012 and October 2018 identified pediatric patients listed allergic to egg, soy, and/or peanut, who received propofol. Allergy testing and results are presented. Evidence of allergic reaction to propofol during anesthesia was evaluated, and compared with a large nonallergic cohort who received propofol.

Results: Of the 232 392 anesthetics administered, 177 360 (76%) included propofol and 11308 (6%) involved a patient listed allergic to at least 1 index food. A large number of patients had no food allergy testing (n = 6153) or negative testing (n = 2198). Of the 3435 patients listed egg-allergic, 976 tested positive; 750 tested negative; and 1709 had no testing. Of the 2011 patients listed soy-allergic, 322 tested positive; 585 tested negative; and 1104 had no testing. Additionally, 5862 patients were listed peanut-allergic; 1659 tested positive; 863 tested negative and 3340 had no testing. One record of proven propofol anaphylaxis occurred; it was in a patient without a history of food allergies. There were 6 other cases of suspected allergy to propofol. One had a peanut and tree nut allergy and was lost to follow-up; one had no testing available, while 4 patients had positive propofol allergy testing and positive allergy tests to other medications. The rate of proven propofol anaphylaxis during anesthesia in the nonallergic cohort was 0.06/10 000, and the rate in egg- and soy-allergic patients was 0/5446. One patient with a listed peanut allergy had a possible reaction to propofol.

Conclusions: In the listed food-allergic cohort, the majority had no allergy testing or negative testing. We found no evidence of a relationship between food allergy history and perioperative propofol reaction. We suggest multiply allergic and atopic patients may have a similar likelihood of propofol reaction as with other medications.

Abstract
Background: Administering antibiotics is often difficult in patients with specific medication allergies. This investigation aimed to determine if a penicillin or cephalosporin allergy increased the risk for not receiving correct timing of prophylactic antibiotics at cesarean delivery. We hypothesized that patients with a penicillin or cephalosporin allergy would be less likely to receive antibiotics prior to incision for cesarean delivery.

Methods: All women undergoing cesarean delivery at Mayo Clinic Hospital, from 1 March 2008, to 28 February 2018 were retrospectively identified by electronic medical record query. Patients were grouped based on allergy status to penicillin/cephalosporins. Data recorded included the type and time of antibiotic given in relation to surgical incision. The primary outcome of this study was administration of antibiotics within 60 minutes prior to surgical incision. Characteristics potentially associated with the primary outcome were assessed using logistic regression.

Results: Of the 818 patients with a penicillin or cephalosporin allergy, 75 (9.2%) did not receive prophylactic antibiotic within 60 minutes prior to skin incision. Conversely, 326 (6.9%) of the 4744 patients without a penicillin or cephalosporin allergy did not receive their prophylactic antibiotic within 60 minutes prior to skin incision (P = .019). Patients undergoing an emergent cesarean delivery were also at an increased risk of not receiving their prophylactic antibiotic within 60 minutes prior to skin incision (P < .001).

Conclusion: Patients with a penicillin or cephalosporin allergy were less likely to receive prophylactic antibiotics within the recommended 60 minutes prior to surgical incision. Clear plans and communication are important for ensuring proper antibiotic administration at cesarean delivery to prevent surgical site infection.

Abstract
Background: Pediatric perioperative hypersensitivity reactions are rare, and possibly life-threatening. Identification of precise etiology is crucial to circumvent future re-exposures.

Aims: We aim to evaluate the clinical features and triggers of perioperative hypersensitivity reactions in children, and determine the outcomes of subsequent general anesthesia.

Methods: A retrospective study was performed with patients who underwent skin testing for general anesthesia between 2007 and 2019. We noted demographic features and skin tests (neuromuscular blocking agents, induction agents, and antibiotics). We also recorded specific Immunoglobulin Es or provocation results of drugs or substances (latex, chlorhexidine, and ethylene oxide) that patients were exposed to antecedent to the reaction. Telephone interviews were performed to determine the current status of the participants and reconsider subsequent anesthesia.

Results: We enrolled 50 children (58% male) with a suspected perioperative hypersensitivity reaction. The median age was 6.67 (4.4-11.5) years, and the median time between the reaction, and skin tests was 4 (1-36) months. The most common potential causative agents were neuromuscular blocking agents (n=8), midazolam (n=3), ketamine (n=2), and propofol (n=1). Three children exhibited hypersensitivity to more than one general anesthetics, and three patients were allergic to latex. Thirty-one patients received subsequent anesthesia, and only one patient had a hypersensitivity reaction. A previous history multiple of general anesthesia administration (≥ 2) increased the risk of reaction to neuromuscular blocking agents.

Conclusion: Data on perioperative hypersensitivity reactions during childhood is rare due to limited diagnostic procedures. Different preference of general anesthetics may change the causative agent. Meticulous evaluation is necessary to safely administer subsequent anesthesia.