Systemic anaphylaxis induced by intradermal testing.

We report the case of a patient who was referred for suspected anaphylaxis with anesthetic drugs. Gallamine was diagnosed the responsible drug and our patient developed anaphylaxis during intradermal testing (IDT) with this compound. IDT should be monitored carefully.

Persistence of allergy to anaesthetic drugs.

Intradermal testing and RIA testing for specific IgE antibodies to neuromuscular blocking drugs (NMBDs) were performed in patients referred to an Anaesthetic Allergy Clinic. Six patients were initially investigated four to 29 years after clinical anaphylaxis during anaesthesia and two of these patients and sixteen others were investigated by intradermal testing on two occasions at least four years apart. Seven patients had RIA tests for NMBD-specific IgE antibodies on two occasions at the time of skin testing. In all but two patients the evidence for drug-specific antibodies persisted 4-29 years after the reactions. In one patient all tests became negative and in another the skin test became negative but the positive RIA persisted. Evidence of antibodies to NMBDs persisted in 21 of 22 patients who had had anaphylactic reactions to these drugs during anaesthesia. In the absence of evidence of allergy diminishing with time in the majority of patients it would seem wise to avoid drugs responsible for reactions for the rest of the patient's life.

Anaphylaxis to muscle relaxants: cross-sensitivity studied by radioimmunoassays compared to intradermal tests in 34 cases.

Thirty-four patients (31 female and three male patients) with a previous anaphylactoid shock to muscle relaxants were investigated. The seric antimyorelaxant IgE was detected by radioimmunoassay (RIA), and the results were compared to intradermal test (IDR) reactions to dilutions of the commercial drugs. The RIA was carried out with a Sepharose-myorelaxant solid phase and anti-IgE 125I-labeled IgG. The results corresponded to the percentage of labeled anti-IgE bound on the solid phase. The RIA with Sepharose-alcuronium and Sepharose-choline was estimated positive from determination with normal sera (n = 12) when bound IgE was greater than 1.0% and 1.5%, respectively. The RIA and IDR were positive in 43.5% and 75%, respectively, of the cases, with a concordance of 66%. One test at least was positive in 79.4% of the cases. No correlation was found between IgE seric levels and the RIA nor between the cutaneous sensitivity and the RIA. Cross-reactivity with Sepharose-choline and Sepharose-alcuronium was observed in 50%, and it was demonstrated by IDR in only 34.2%. The RIA demonstrated the specificity of IgE to quaternary ammonium compounds as myorelaxant drugs. The positive IDR revealed the bridging of mast cell-bound specific IgE, depending on structural conditions, such as the flexibility of the molecules or the variable specificity of the antibodies, restricted to quaternary ammonium ions or enlarged to a broader part of the incriminated molecules.

Allergy to suxamethonium: persisting abnormalities in skin tests, specific IgE antibodies and leucocyte histamine release.

Twenty-one patients, who had previously experienced an anaphylactic reaction to suxamethonium during general anaesthesia, were selected for this study. Initially, skin tests with muscle relaxants were carried out in the twenty-one patients, detection of specific anti-choline IgE in nineteen, and leucocyte histamine release in seventeen. These three tests were then repeated between 1 year and 4 years after the initial evaluation. In the majority of patients, sensitization to the muscle relaxants persisted for more than 1 year after the anaphylactic reaction. Only three patients out of twenty-one (4%) had negative skin tests when retested 1-4 years later. A reduction in leucocyte histamine release was noticed in one of the seventeen retested patients (6%). Modifications of anti-choline IgE were observed in five of nineteen patients (26%). The persistence of sensitization to suxamethonium may result from repeated stimulation by occasional contacts with quaternary ammonium compounds. This study demonstrates the reliability of skin tests, leucocyte histamine release and detection of anti-choline IgE to diagnose allergic reactions to suxamethonium, even when they are performed a long time after the initial anaphylactic reaction.

Anaphylaxis to precurarising doses of gallamine triethiodide.

Two cases are described in which patients developed acute anaphylactic reactions to precurarising doses of gallamine. Life threatening complications can arise from the use of small doses of drugs as adjuncts to anaesthesia and raises the question whether the benefits of precurarisation outweigh the risks of anaphylaxis.

Anaphylactoid reactions during anaesthesia. Seven years' experience of intradermal testing.

Sixty one patients who had suffered intra-operative anaphylactoid reactions were studied. Intradermal testing identified the causative agent in 84% of cases and, in 75% of these, muscle relaxants were responsible. Predisposing factors in patients sensitive to muscle relaxants were: female sex, previous allergy and atopy. The incidence of previous exposure was considerably higher than that reported in the literature. Pancuronium is suggested to be the least likely currently available agent to provoke a major anaphylactoid reaction.

Anaphylactic reaction to thiopentone: a case report.

A 32-year-old female was admitted for a minor elective surgical procedure. Her past history included at least six uneventful general anaesthetics. Anaphylaxis developed shortly following induction of anaesthesia with thiopentone, Innovar and gallamine. Resuscitation was successful but was complicated by ventricular fibrillation. Full recovery followed. Subsequent allergy skin tests revealed hypersensitivity to thiopentone. Recommendations for investigation of suspected hypersensitivity to anaesthetic agents are included, as are guidelines for the recognition and treatment of anaphylaxis.

Cardiovascular effects of nondepolarizing relaxants employed for pretreatment prior to succinylcholine.

A pregnant woman with severe pre-eclampsia experienced a hypertensive crisis following a pretreatment dose (20 mg) of gallamine. That episode initiated a study to determine the cardiovascular effects of non-depolarizing muscle relaxants in 58 nonobese, ASA physical status I and II adults. Subjects were assigned randomly to one of five treatment groups as follows: gallamine (0.29 mg X kg-1), d-tubocurarine (0.04 mg X kg-1), metocurine (0.014 mg X kg-1), pancuronium (0.007 mg X kg-1), or normal saline (control). Baseline measurements of systolic, diastolic, mean arterial pressure, heart rate (HR) and rate pressure product (calculated RPP) were recorded at one-minute intervals while electrocardiogram, lead II, was recorded continuously. Statistically significant increases occurred in HR at minutes 2, 3 and 4; RPP at minutes 3 and 4; and per cent change in HR at minutes 2, 3 and 4 following gallamine pretreatment. The rise in RPP was predominantly due to the elevation in HR. These results suggest that even modest doses of gallamine should be avoided in clinical situations where lability of cardiovascular dynamics can be anticipated.

Anaphylactoid reactions to neuromuscular blocking agents: a commonly undiagnosed condition?

A group of 28 patients with extreme, life-threatening sensitivity to suxamethonium was identified and 15 were studied in detail by skin-testing. The female/male ratio was 8/1. Sensitivity may be present without previous exposure to suxamethonium; in 3 patients reactions occurred during the first exposure to anaesthesia. Most patients showed one or more cross-sensitivities to alcuronium, tubocurarine, and gallamine. Signs of circulatory collapse were the sole presenting feature in 50% of the patients. Histamine release induced by the drug in vitro was demonstrated in some instances.

Adverse reaction to methohexitone and gallamine.

A case is presented in which a patient developed an acute anaphylactoid reaction after receiving methohexitone and gallamine for the induction of anaesthesia. The problem of eliciting the responsible agent is discussed, which comments on the method of treatment and preventative measures.

Relation of precurarization to suxamethonium to provide ease of intubation and to prevent post-suxamethonium muscle pains.

Tubocurarine 0.05 and 0.07 mg.kg-1, gallamine 0.1 and 0.2 mg.kg-1 and pancuronium 0.01 and 0.02 mg.kg-1 given three minutes before suxamethonium 1.0, 1.5 and 2 mg.kg-1 in groups of 10 patients each (total 210 patients) to compare ease of tracheal intubation and incidence of post-suxamethonium muscle pain. These were compared with a control group of suxamethonium 1.0, 1.5 and 2 mg.kg-1 given alone after thiopentone 5 mg.kg-1. On analysis, tubocurarine 0.07 mg.kg-1 and suxamethonium 2 mg.kg-1 was the ideal combination with the best intubation conditions and the lowest incidence of post-suxamethonium muscle pains. The second best combination was gallamine 0.2 mg.kg-1 and suxamethonium 2 mg.kg-1. Pancuronium 0.01 mg.kg-1 and 0.02 mg.kg-1 in combination with suxamethonium 2 mg.kg-1 were satisfactory, although less efficient than the combination with either tubocurarine or gallamine.