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Anaesthetic allergy: Anaphylaxis management guidelines & references

This page contains links to the Anaphylaxis Management Guidelines, which can be read in full on the ANZAAG website. There are also links to articles, where possible, from the reference list to support these guidelines. Where articles are unavailable online, they can be requested from the ANZCA Library.

ANZAAG Anaphylaxis Management Guidelines

The documents listed below are designed to be used as a crisis management package in the event of an acute perioperative anaphylaxis. We recommend all members of your department are aware of their content and how to use each card or section. Please take the time to read the introduction and each of the cards carefully. Optimum use will occur when clinicians are well prepared and have used the resource to practise crisis management prior to an event.

Please note:  If you are having problems downloading or printing these documents, ensure you have the latest version of Adobe Reader installed. This is a free program for viewing and printing PDF documents.

ANZAAG recommends the management documents are stored in an agreed location known to staff in operating theatres eg. with an Anaphylaxis Box or on the cardiac arrest trolley. 

Anaphylaxis Box documents are available here on the ANZAAG website

Provide feedback to ANZAAG regarding the Anaphylaxis Management Documents by sending email to 

Chlorhexidine allergy

Acute Anaphylaxis Clinical Care Standard

ANZAAG Anaphylaxis Management Guidelines References

1. ​Marshall SD, Sanderson P, McIntosh CA, Kolawole H. The effect of two cognitive aid designs on team functioning during intra-operative anaphylaxis emergencies: A multi-centre simulation study. Anaesthesia. 2016;71(4):389-404.

2. Truhlar A et al. European Resuscitation Council guidelines for resuscitation 2015 section 4 cardiac arrest in special circumstances. Resuscitation. 2015;95:148–201.

3. Lavonas EJ, et al. Part 10: special circumstances of resuscitation: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132:S501-S518.

4. Muraro A, et al. EAACI food allergy and anaphylaxis guidelines group. Anaphylaxis: guidelines from the European Academy of Allergy and Clinical Immunology. Allergy. 2014;69(8):1026-45.

5. Simons FE, et al. World Allergy Organization. World Allergy Organisation Anaphylaxis Guidelines: 2013 update of the evidence base. Int Arch Allergy Immunol. 2013;162(3):193-204. 

6. Simons FE, et al. World Allergy Organisation guidelines for the assessment and management of anaphylaxis.  WAO Journal 2011;4:13-37.

7. Vanden Hoek TL, Morrison LJ, Shuster M, Donnino M. Part 12: Cardiac arrest in special situations: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010;122:S829-861. 

8. Australian Resuscitation Council and New Zealand Resuscitation Council. Guideline 11.10 Resuscitation in special circumstances. November 2011.

9. Sheikh A, Shehata YA, Brown SGA, Simons FE. Adrenaline for the treatment of anaphylaxis with and without shock. The Cochrane Library 2010;10:1-17. 

10. Mertes PM, Malinovsky JM, Jouffrou L et al. Reducing the risk of anaphylaxis during anesthesia: 2011 updated for clinical practice. J Investig Allergol Clin Immunol 2011;21:442-453.

11. Association of Anaesthetists of Great Britain and Ireland. Suspected anaphylactic reaction associated with anaesthesia. Anaesthesia 2009;64:199-211. 

12. Rose M, Fisher M. Anaphylaxis and anaesthesia. What can we do better? Australasian Anaesthesia 2009: 115-119. 

13. Kroigaard M et al. Scandinavian clinical practice guidelines on diagnosis, management and follow up of anaphylaxis during anaesthesia. Acta Anaesthesiol Scand 2007;51:655-70. 

14. Australasian Society of Clinical Immunology and Allergy. Anaphylaxis: emergency management for health professionals (poster) Australian Prescriber 2011; 34.

15. Brown SGA, Mullins RJ, Gold MS. Anaphylaxis: diagnosis and management. Med J Aust 2006;185:283-289. 

16. Marshall S. The use of cognitive aids during emergencies in anesthesia: a review of the literature. Anesth Analg 2013;117:1162–71.

17. Burden AR, Carr ZJ, Staman GW, Littman JJ, Torjman MC. Does every code need a "reader?" improvement of rare event management with a cognitive aid "reader" during a simulated emergency: a pilot study. Simul Healthc. 2012 Feb;7(1):1-9. 

18. P.M. Mertes, et al. Perioperative anaphylaxis. Immunol Allergy Clin North Am. 2009 Aug;29(3):429-51.

19. Hepner DL & Castells MC. Anaphylaxis during the perioperative period. Anesth Analg. 2003;97:1381-95.

20. Brown SGA. Cardiovascular aspects of anaphylaxis: implications for treatment and diagnosis. Curr Opin Allergy Clin Immunol. 2005; 5:359–364.

  • Request this article from the Library.

21. Fisher MM, Ramakrishnan N, Doig G, Rose M & Baldo B. The investigation of bronchospasm during induction of anaesthesia. Acta Anaesthesiol Scand 2009; 53:1006–1011.

22. Mertes PM, Laxenaire MC, Alla F. Groupe d’etudes des reactions anaphylactoides peranesthesiques. Anaphylactic and anaphylactoid reactions occurring during anesthesia in France in 1999–2000. Anesthesiology. 2003;99:536–45. 

23. The Australian and New Zealand Committee on Resuscitation. Guideline 11.2 Protocols for Adult Advanced Life Support. January 2016.

24. Link MS et al. 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Part 7: Adult advanced cardiovascular life support. Circulation 2015;132:S444-464. 

25. Reddy JI, Cooke PJ, van Schalkwyk JM et al. Anaphylaxis Is more common with rocuronium and succinylcholine than with atracurium. Anesthesiology. 2015;122:39-45. 

26. Gibbs NM, Sadleir PH, Clarke RC, Platt PR. Survival from perioperative anaphylaxis in Western Australia 2000–2009. Br J Anaesth. 2013;111:589-93 

27. Sadleir PH, Clarke RC, Bunning DL, Platt PR. Anaphylaxis to neuromuscular blocking drugs: incidence and cross-reactivity in Western Australia from 2002–2011. Br J Anaesth. 2013;110: 981–7. 

28. Brereton A, Russell WJ. Anaphylaxis to muscle relaxants: an audit of ten years of allergy testing at the Royal Adelaide Hospital. Anaesth Intensive Care. 2012;40(5):861-6. 

29. McNeill O, Kerridge RK, Boyle MJ. Review of procedures for investigation of anaesthesia-associated anaphylaxis in Newcastle, Australia. Anaesth Intensive Care. 2008;36(2):201-7.

30. Sharp G, Green S, Rose M. Chlorhexidine-induced anaphylaxis in surgical patients: a review of the literature. ANZ J Surg. 2016; 86(4):237-43.

  • Request this article from the Library.

31. Jee R, et al. Four cases of anaphylaxis to chlorhexidine impregnated central venous catheters: a case cluster or the tip of the iceberg? Br J Anaesth. 2009 Oct;103(4):614-5.

32. ANZCA Professional Documents. PS 60 Guidelines on the perioperative management of patients with suspected of proven hypersensitivity to chlorhexidine, 2015. 

33. Pumphrey RSH. Fatal posture in anaphylactic shock. J Allergy Clin Immunol. 2003;112;451-452. 

34. Pumphrey RS. Lessons for the management of anaphylaxis from a study of fatal reactions. Clin Exp Allergy. 2000;30:1144-50.

  • Request this article from the Library.

35. Clarke R, Sadleir PHM, Van Niekerk AW, Platt P. Quantification of volume loss and haemodynamic changes of Gelofusine®-induced anaphylaxis during cardiopulmonary bypass. Anaesth Intensive Care. 2011;39:492-495.

36. Brown SGA, Blackman KE, Stenlake V, Heddle RJ. Insect sting anaphylaxis; prospective evaluation of treatment with intravenous adrenaline and volume resuscitation. Emerg Med J. 2004;21:149-154. 

37. Fisher MM. Clinical observations on the pathophysiology and treatment of anaphylactic cardiovascular collapse. Anesth Intensive Care. 1986;14:17-21

38. Tajima K et al. Time to achieve target mean arterial pressure during resuscitation from experimental anaphylactic shock in an animal model. A comparison of adrenaline alone or in combination with different volume expanders. Anaesth Intensive Care. 2013;41(6):765-73.

39. Kemp SF et al. Epinephrine: the drug of choice for anaphylaxis. A statement of the World Allergy Organisation. Allergy 2008;63: 1061-1070. 

40. McLean-Tooke APC, Bethune CA, Fay AC, Spickett GP. Adrenaline in the treatment of anaphylaxis: what is the evidence? BMJ 2003;327:1332-1335. 

41. Campbell RL, et al. Epinephrine in anaphylaxis: higher risk of cardiovascular complications and overdose after administration of intravenous bolus epinephrine compared with intramuscular epinephrine. J Allergy Clin Immunol in Pract. 2015;3(1):76–80.

42. Shaver KJ, et al. Acute myocardial infarction after administration of low-dose intravenous epinephrine for anaphylaxis. CJEM 2006;8:289–294. 

43. Pumphrey R. Anaphylaxis: can we tell who is at risk of a fatal reaction? Curr Opin Allergy Clin Immunol. 2004;4:285–290.

  • Request this article from the Library.

44. Johnston SL, Unsworth J, Gompels MM. Adrenaline given outside the context of life threatening allergic reactions. BMJ. 2003;326:589–590.

45. Garvey LH, Belhage B, Kroigaard M. Treatment with epinephrine (adrenaline) in suspected anaphylaxis during anaesthesia in Denmark. Anesthesiology. 2011;115:111-6. 

46. Simons FE, Gu X, Simons KJ. Epinephrine absorption in adults: intramuscular versus subcutaneous injection. J Allergy Clin Immunol. 2001;108:871–87. 

47. Simons FE, Roberts JR, Gu X, Simons KJ. Epinephrine absorption in children with a history of anaphylaxis. J Allergy Clin Immunol. 1998;101(1 Pt 1):33-37.

48. Mink SN, Simons FE, Simons KJ, Becker AB, Duke K. Constant infusion of epinephrine, but not bolus treatment, improves haemodynamic recovery in anaphylactic shock in dogs. Clin Exp Allergy. 2004;34:1776–1783.

  • Request this article from the Library.

49. Shann F. Drug Doses. 16th Edition 2014. Royal Children’s Hospital, Melbourne. 

50. Clarke RC, Sadleir PHM & Platt PR. The role of sugammadex in the development and modification of an allergic response to rocuronium: evidence from a cutaneous model. Anaesthesia. 2012;67:266–273.

51. Tomak Y, Yilmaz A, Bostan H, et al. Effects of sugammadex and rocuronium mast cell number and degranulation in rat liver. Anaesthesia 2012;67:1101–4. 

52. Platt PR, Clarke RC, Johnson GH and Sadleir PHM. Efficacy of sugammadex in rocuronium-induced or antibiotic- induced anaphylaxis. A case–control study. Anaesthesia. 2015;70(11):1264-7.

53. Australian Resuscitation Council and New Zealand Resuscitation Council. Guideline 12.1 Introduction to Paediatric Advanced Life Support.

54. O’Meara M & Watton DJ. Advanced Paediatric Life Support: The Practical Approach. Appendix J Formulary. 5th [Australian] ed. 2013. Blackwell, West Sussex.

55. ANZCA Professional Standards. PS 18 Recommendations on Monitoring during Anaesthesia, 2008 + background paper.

56. Tan CO, et al. Successful resuscitation of class 4 anaphylaxis guided by transthoracic echocardiography. Anaesth Intensive Care. 2014;42(1):144-5. 

57. Weiss GM; Fandrick AD; Sidebotham D. Successful rescue of an adult with refractory anaphylactic shock and abdominal compartment syndrome with venoarterial extracorporeal membrane oxygenation and bedside laparotomy. Semin Cardiothorac Vasc Anesth. 2015;19(1):66-70.

58. Schummer C, Wirsing M, Schummer W. The pivotal role of vasopressin in refractory anaphylactic shock. Anesth Analg. 2008;107: 620-624. 

59. Meng L. Treatment of rocuronium-induced anaphylactic shock with vasopressin. Can J Anaesth. 2008;55:437–440.

60. Dewachter P, Raeth-Fries I, Jouan-Hureaux V, et al. A comparison of epinephrine only, arginine vasopressin only, and epinephrine followed by arginine vasopressin on the survival rate in a rat model of anaphylactic shock. Anesthesiology 2007;106:977–83.

61. Green R, Ball A. Alpha-agonists for the treatment of anaphylactic shock. Anaesthesia. 2005;60:621–622. 

62. Heytman M, Rainbird A. Use of alpha-agonists for management of anaphylaxis occurring under anaesthesia: case studies and review. Anaesthesia. 2004;59:1210–1215. 

63. Kill C, Wranze E, Wulf H. Successful treatment of severe anaphylactic shock with vasopressin. Two case reports. Int Arch Allergy Immunol. 2004;134:260–1.

  • Request this article from the Library.

64. Thomas M, Crawford I. Best evidence topic report. Glucagon infusion in refractory anaphylactic shock in patients on beta-blockers. Emerg Med J. 2005;22:272-273. 

65. Lavonas EJ, Drennan IR et al. Part 10: Special circumstances of resuscitation 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2015;132:S501-518. 

66. Simons FER, Schatz, M. Anaphylaxis during pregnancy. J Allergy Clin Immunol. 2012;597-605. 

67. Lipman S, et al. The Society for Obstetric Anesthesia and Perinatology Consensus Statement on the Management of Cardiac Arrest in Pregnancy. Anesth Analg. 2014;118:1003–16. 

68. Lampin ME, et al. Noradrenaline use for septic shock in children: doses, routes of administration and complications. Acta Paediatrica. 2012;101:426–30.

  • Request this article from the Library.

69. Carroll TG, et al. Vasopressin rescue for in-pediatric intensive care unit cardiopulmonary arrest refractory to initial epinephrine dosing: a prospective feasibility pilot trial. Pediatr Crit Care Med 2012;13(3):265–272.

  • Request this article from the Library.

70. Di Chiara L, et al. Role of vasopressin in the treatment of anaphylactic shock in a child undergoing surgery for congenital heart disease: a case report. J Med Case Rep. 2008;2:36. 

71. Choo KJL, Simons E, Sheikh A. Glucocorticoids for the treatment of anaphylaxis: Cochrane systemic review. Allergy. 2010;65 1205-1211. 

72. Tole JW, Lieberman P. Biphasic anaphylaxis: review of incidence, clinical pre- dictors, and observation recommendations. Immunol Allergy Clin North Am. 2007;27:309–26. 

73. Sheikh A, Ten Broek V, Brown SG, Simons FE. H1-antihistamines for the treatment of anaphylaxis: Cochrane systematic review. Allergy. 2007;62:830-837. 

74. Ellis BC, Brown SG. Parenteral antihistamines cause hypotension in anaphylaxis. Emerg Med Australas. 2013;25:92–93.

75. Ebo DG, Fisher MM, Hagendorens MM, Bridts CH, Stevens WJ. Anaphylaxis during anaesthesia: diagnostic approach. Allergy 2007;62:471-487.

76. Schwartz LB. Diagnostic value of tryptase in anaphylaxis and mastocytosis. Immunol Allergy Clin N Am. 2006;26:451-463.

  • Request this article from the Library.

77. Truong HT & Browning RM. Anaphylaxis-induced hyperfibrinolysis in pregnancy. Int J Obstet Anesth 2015 May;24(2):180-5 

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