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BACKGROUND: Maximal skin testing (ST) nonirritant concentrations (NICs) are consistent for penicillin and aminopenicillin among guidelines. However, there is variability among guidelines for maximal ST NICs of cephalosporins. OBJECTIVE: To determine maximal immediate and delayed ST NICs of 15 ß-lactams in ß-lactam-tolerant and ß-lactam-naïve participants. METHODS: We performed a single-center, nonrandomized prospective study between September 2019 and January 2022 in adult participants. Participants received skin prick testing (SPT) and intradermal test (IDT) injections at 6 increasing concentrations of 1 or more ß-lactams. A concentration was considered irritant when more than 5% of participants had a positive test. A positive test was defined as a wheal ≥3 mm compared with negative control accompanied by a ≥5 mm flare for SPT/IDT and induration ≥5 mm with associated erythema at 48 hours for delayed readings (dIDT). Sensitivity analyses using 3 alternative IDT positive criteria were conducted. RESULTS: A total of 747 participants with a median age of 64 (interquartile range: 54-72) years (52% male, 85% White, and 92% non-Hispanic) underwent 20,858 skin tests. All undiluted SPT concentrations were nonirritant. We found the following maximal IDT/dIDT NICs (mg/mL): ampicillin (41.6/125), ampicillin-sulbactam (93.8/187.5), aztreonam (6.3/25), cefazolin (55/165), cefepime (35/140), cefoxitin (45/90), ceftaroline (7.5/15), ceftriaxone (58.3/175), cefuroxime (55/110), ertapenem (16.6/50), imipenem-cilastin (6.3/25), meropenem (8.3/25), nafcillin (31.3/62.5), oxacillin (20.9/83.5), and piperacillin-tazobactam (112.5/225). dIDTs were almost all completely nonirritant close to or at undiluted concentrations. There were no differences when we applied 3 IDT positivity criteria to our raw data. CONCLUSIONS: Our results suggest that SPTs with undiluted stock ß-lactam antibiotic concentrations are nonirritant. Compared with previously published nonirritant concentrations, we propose a 2- to 50-fold increase to the maximal IDT and dIDT NICs of 15 ß-lactam antibiotics. When performing dIDTs, a higher concentration should be used rather than the same IDT concentration.
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BACKGROUND: Perioperative anaphylaxis is a serious and often life-threatening immediate hypersensitivity reaction. There are few published data on paediatric perioperative anaphylaxis (pPOA). We evaluated the incidence of and risk factors involved in the occurrence of pPOA within a large US national database. METHODS: Deidentified data from the US Nationwide Inpatient Sample from 2005 to 2014 were used to identify pPOA cases and to conduct a retrospective multivariate analysis of preselected independent variables. RESULTS: Among 3,601,180 surgeries and procedures in children aged 0-18 yr, 297 pPOA cases were identified for an incidence of one in 12,125 surgeries and procedures. Compared with controls, pPOA cases had an increased median length of stay (6 vs 2 days; P<0.001) and median hospital cost ($54 719 vs $5109; P<0.0001). The age groups between 6 and 12 yr (odds ratio [OR] 7.1; 95% confidence interval [CI] 3.9-12.9; P<0.001) and 13 and 17 yr (OR 8.5; 95% CI 4.7-15.2; P<0.001) were associated with increased odds of pPOA. Transplant (OR 46.3; 95% CI 20.8-102.9; P<0.001), cardiac (OR 16.4; 95% CI 7.5-35.9; P<0.001), and vascular (OR 15.2; 95% CI 7.5-30.7; P<0.001) procedures posed the highest risk for pPOA. Chronic pulmonary disease, coagulopathy, and fluid and electrolyte disorders were also associated with pPOA (OR 2.2; 95% CI 1.5-3.3; P<0.001). CONCLUSIONS: The incidence of pPOA was one in 12,125 cases. Risk factors included age, procedure type, and comorbidities.
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Anafilaxia , Periodo Perioperatorio , Factores de Riesgo , Periodo Perioperatorio/estadística & datos numéricos , Anafilaxia/epidemiología , Estados Unidos/epidemiología , Incidencia , Estudios Retrospectivos , Análisis Multivariante , Humanos , Masculino , Femenino , Lactante , Preescolar , Niño , Adolescente , Recién NacidoRESUMEN
BACKGROUND: US-based perioperative anaphylaxis (POA) studies are limited to single-center experiences. A recent report found that a serum acute tryptase (sAT) >9.8 ng/mL or mast cell activation (MCA) can predict POA causal agent identification. Urinary mast cell mediator metabolites (uMC) have not been studied in POA. OBJECTIVE: To analyze the epidemiologic data of POA, to determine if sAT or MCA can predict suspected causal agent identification, and to evaluate uMC utility in POA. METHODS: This study is a retrospective multicenter review of POA cases that were subcategorized by suspected causal agent identification status. sAT, MCA (defined as sAT >2 + 1.2 × serum baseline tryptase), and uMC (N-methylhistamine [N-MH], 11ß-prostaglandin-F2α [11ß-PGF2α], leukotriene E4 [LTE4]) were recorded. RESULTS: Of 100 patients (mean age 52 [standard deviation 17] years, 94% adult, 50% female, 90% White, and 2% Hispanic) with POA, 73% had an sAT available, 41% had MCA, 16% had uMC available, and 50% had an identifiable suspected cause. POA cases with an identifiable suspected cause had a positive MCA status (100% vs 78%; P = .01) compared with POA with an unidentifiable cause. An elevated median sAT did not predict causal agent identification. Positive uMC were not associated with suspected causal agent identification during POA. Patients with positive uMC had a higher median sAT (30 vs 6.45 ng/mL; P = .001) and MCA status (96% vs 12%; P = .001) compared with negative uMC patients. Patients with POA had an elevated acute/baseline uMC ratios: 11ß-PGF2α ratio > 1.6, N-MH ratio >1.7, and LTE4 ratio >1.8. CONCLUSIONS: The presence of MCA in POA is associated with suspected causal agent identification. Positive uMC possibly correlate with a higher sAT level and MCA status but require further study. The authors suggest applying an acute/baseline uMC ratio (11ß-PGF2α ratio >1.6, N-MH ratio >1.7, and LTE4 ratio >1.87) in patients with POA for MCA when a tryptase level is inconclusive during POA evaluations.
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Anafilaxia , Periodo Perioperatorio , Triptasas , Humanos , Anafilaxia/epidemiología , Anafilaxia/diagnóstico , Femenino , Estudios Retrospectivos , Masculino , Persona de Mediana Edad , Triptasas/sangre , Adulto , Estados Unidos/epidemiología , Anciano , Mastocitos/inmunologíaRESUMEN
BACKGROUND: Using the reaction history in logistic regression and machine learning (ML) models to predict penicillin allergy has been reported based on non-US data. OBJECTIVE: We developed ML positive penicillin allergy testing prediction models from multisite US data. METHODS: Retrospective data from 4 US-based hospitals were grouped into 4 datasets: enriched training (1:3 case-control matched cohort), enriched testing, nonenriched internal testing, and nonenriched external testing. ML algorithms were used for model development. We determined area under the curve (AUC) and applied the Shapley Additive exPlanations (SHAP) framework to interpret risk drivers. RESULTS: Of 4777 patients (mean age 60 [standard deviation: 17] years; 68% women, 91% White, and 86% non-Hispanic) evaluated for penicillin allergy labels, 513 (11%) had positive penicillin allergy testing. Model input variables were frequently missing: immediate or delayed onset (71%), signs or symptoms (13%), and treatment (31%). The gradient-boosted model was the strongest model with an AUC of 0.67 (95% confidence interval [CI]: 0.57-0.77), which improved to 0.87 (95% CI: 0.73-1) when only cases with complete data were used. Top SHAP drivers for positive testing were reactions within the last year and reactions requiring medical attention; female sex and reaction of hives/urticaria were also positive drivers. CONCLUSIONS: An ML prediction model for positive penicillin allergy skin testing using US-based retrospective data did not achieve performance strong enough for acceptance and adoption. The optimal ML prediction model for positive penicillin allergy testing was driven by time since reaction, seek medical attention, female sex, and hives/urticaria.
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Hipersensibilidad a las Drogas , Aprendizaje Automático , Penicilinas , Humanos , Femenino , Penicilinas/efectos adversos , Masculino , Hipersensibilidad a las Drogas/epidemiología , Hipersensibilidad a las Drogas/diagnóstico , Estudios Retrospectivos , Persona de Mediana Edad , Estados Unidos/epidemiología , Anciano , Adulto , Antibacterianos/efectos adversos , Estudios de Casos y Controles , Pruebas CutáneasRESUMEN
Background: A previous study, using administrative data, reported an incidence of perioperative anaphylaxis (POA) of 1:6537 procedures in the United States. Objective: We sought to determine the incidence of POA in a prospective US cohort. Methods: Adult participants undergoing a procedure at a single tertiary care center were studied prospectively between April 2018 and January 2022. Subinvestigators recorded vital signs and skin checks preoperatively, 15 minutes into induction, and hourly thereafter until 1 hour into the postoperative period. If participants developed an adverse reaction, additional variables were documented: causal agent(s) exposure, type of nonallergic adverse reaction, Sixth National Audit Project severity score, evidence of mast cell activation by serum acute and baseline tryptase pairing, Allergy consult, and causal agent identification. Results: Among 939 procedures (mean age, 59.25 ± 14.78 years; 58% females; 87% White), there were 12 (1.3%) cases with an identified adverse reaction. Nine cases were classified as nonhypersensitivity adverse reactions (1%) and 3 as possible hypersensitivity reactions (0.3%); 1 case was classified as suspected perioperative hypersensitivity and 2 as POA (0.2%). Both POA cases were males, had previous procedures, had evidence of mast cell activation, had a Sixth National Audit Project score of 3, and were referred to Allergy for further evaluation. There were 9 participants who developed a nonhypersensitivity adverse reaction: relative overdose of anesthetic (n = 6), transient rash (n = 2), and isolated bronchospasm (n = 1). All transient rashes were observed during undraping protocol. Conclusions: In our prospective study, the incidence of POA is 1:470 procedures. Our study suggests that the incidence of POA may be higher than previously reported.
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PURPOSE: Patients with mastocytosis have an increased risk of anaphylaxis during surgical procedures with general anesthesia. Therefore, we reviewed the anesthesia course of a large cohort of patients with mastocytosis. METHODS: We retrospectively reviewed adult and pediatric patients with mastocytosis who underwent surgical procedures with general anesthesia at Mayo Clinic from January 1, 2000, through June 30, 2021. We also included any procedures with general anesthesia that occurred during the 3-year period preceding mastocytosis diagnosis and designated the patients who underwent these procedures as having an unknown diagnosis at the time of their surgical procedure. We analyzed whether patients received chronic antimediator treatment for mastocytosis and/or prophylactic medications before the procedures. We also determined whether medications indicative of mastocytosis-related adverse events were intraoperatively administered. RESULTS: We identified 113 patients who underwent 219 procedures during the study period; 25 procedures were performed before mastocytosis diagnosis. Of 194 procedures in patients with known mastocytosis, patients received chronic antimediator therapy and/or perioperative prophylactic medications for 178 (91.8%) procedures. Among these procedures, 10 were potentially complicated by mast cell activation, which was inferred from administration of inhaled albuterol (n = 3) or intravenous diphenhydramine (n = 8). In addition, there was only one case of intraoperative anaphylaxis which occurred in a patient who underwent anesthesia before mastocytosis diagnosis and therefore did not receive prophylaxis. CONCLUSION: Intraoperative anaphylaxis can be the first presenting sign of mastocytosis. Patients with mastocytosis who received chronic antimediator therapy and/or preoperative prophylactic medications had an uneventful surgical course.
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Anafilaxia , Mastocitosis , Adulto , Humanos , Niño , Anafilaxia/etiología , Estudios Retrospectivos , Mastocitosis/complicaciones , Mastocitosis/cirugía , Mastocitosis/diagnóstico , Anestesia General/efectos adversos , AlbuterolRESUMEN
Perioperative anaphylaxis is associated with significant morbidity and mortality. Prompt and appropriate treatment is required for optimal outcome. Despite general knowledge of this condition, delays occur in the administration of epinephrine and in particular the use of i.v. route of administration in the perioperative setting. Barriers should be addressed to allow prompt utilisation of i.v. epinephrine in perioperative anaphylaxis.
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Anafilaxia , Humanos , Anafilaxia/tratamiento farmacológico , Epinefrina/uso terapéutico , FluidoterapiaRESUMEN
PURPOSE: Central venous catheters (CVCs) and pulmonary artery catheters (PACs) containing chlorhexidine, silver sulfadiazine, or latex can cause perioperative anaphylaxis. We examined the incidence of and outcomes associated with anaphylaxis caused by CVCs/PACs. METHODS: In a historical cohort study, we retrospectively identified adult patients fitted with CVCs/PACs at the Mayo Clinics in Minnesota, Arizona, and Florida from 1 January 2008 to 1 March 2018. Potential and confirmed cases of perioperative anaphylactic reactions were individually reviewed and classified. RESULTS: During the study period, 39,505 procedures were performed during which CVCs/PACs were inserted. Of these, 2,937 patients with pre-existing chlorhexidine, sulfonamide (sulfa), and/or latex allergies had CVCs/PACs inserted that contained these substances. Perioperative anaphylaxis, in which CVCs/PACs were the confirmed or potential causative agent, occurred during 53 procedures. Seven patients had a preoperatively reported sulfa or latex allergy; no patients had a preoperative chlorhexidine allergy. Six of the seven patients with reported allergies to sulfa or latex had a CVC/PAC inserted that contained these substances. Twenty-four patients with anaphylaxis had postoperative allergic disease consultation; ten of these (42%) underwent skin testing. CONCLUSION: Perioperative anaphylactic reactions related to CVCs/PACs containing chlorhexidine, silver sulfadiazine, or latex were rare in this large historical cohort study. We identified 2,937 patients with pre-existing chlorhexidine, sulfa, and/or latex allergies and had CVCs/PACs inserted that contained these substances. Although few cases of perioperative anaphylaxis attributable to these substances were observed in patients with corresponding allergies, the potential for substantial complication exists. Providers should be aware of the potential for these hidden exposures.
RéSUMé: OBJECTIF: Les cathéters veineux centraux (CVC) et les cathéters artériels pulmonaires (CAP) contenant de la chlorhexidine, de la sulfadiazine argentique ou du latex peuvent provoquer une anaphylaxie périopératoire. Nous avons examiné l'incidence et les devenirs associés à l'anaphylaxie causée par les CVC/CAP. MéTHODE: Dans une étude de cohorte historique, nous avons identifié rétrospectivement des patients adultes chez lesquels un CVC/CAP avait été installé aux cliniques Mayo du Minnesota, de l'Arizona et de la Floride du 1er janvier 2008 au 1er mars 2018. Les cas potentiels et confirmés de réactions anaphylactiques périopératoires ont été examinés et classés individuellement. RéSULTATS: Au cours de la période à l'étude, 39 505 interventions ont été réalisées au cours desquelles des CVC/CAP ont été insérés. Parmi celles-ci, des CVC/CAP contenant de la chlorhexidine, des sulfamides et/ou du latex ont été insérés chez 2937 patients présentant des allergies préexistantes à ces substances. Une anaphylaxie périopératoire, dont l'agent causal confirmé ou potentiel était le CVC/CAP, s'est produite dans 53 interventions. Sept patients présentaient une allergie aux sulfamides ou au latex signalée avant l'opération; aucun patient n'a eu d'allergie préopératoire à la chlorhexidine. Un CVC/CAP contenant des sulfamides ou du latex a été inséré chez six des sept patients ayant signalé des allergies à ces substances. Vingt-quatre patients atteints d'anaphylaxie ont eu une consultation postopératoire pour une maladie allergique; dix d'entre eux (42 %) ont subi des tests cutanés. CONCLUSION: Les réactions anaphylactiques périopératoires liées aux CVC/CAP contenant de la chlorhexidine, de la sulfadiazine argentique ou du latex étaient rares dans cette vaste étude de cohorte historique. Nous avons identifié 2937 patients présentant des allergies préexistantes à la chlorhexidine, aux sulfamides et/ou au latex chez lesquels des CVC/CAP contenant ces substances ont été insérés. Bien que peu de cas d'anaphylaxie périopératoire attribuable à ces substances aient été observés chez des patients présentant des allergies correspondantes, il existe un risque de complication importante. Les fournisseurs doivent être conscients du potentiel de ces expositions cachées.
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Anafilaxia , Cateterismo Venoso Central , Catéteres Venosos Centrales , Hipersensibilidad al Látex , Adulto , Humanos , Clorhexidina/efectos adversos , Sulfadiazina de Plata , Anafilaxia/inducido químicamente , Anafilaxia/epidemiología , Sulfadiazina , Estudios de Cohortes , Hipersensibilidad al Látex/epidemiología , Arteria Pulmonar , Estudios RetrospectivosRESUMEN
BACKGROUND: Skin testing (ST) concentrations of neuromuscular blocking agents (NMBAs), NMBA-reversal agents, and the sugammadex-rocuronium inclusion complex (S-R-Cx) vary widely among reports. OBJECTIVE: To determine maximal ST nonirritant concentrations (NICs) of NMBAs (cisatracurium, rocuronium, succinylcholine, and vecuronium), NMBA-reversal agents (neostigmine and sugammadex), and S-R-Cx in NMBA-tolerant and NMBA-naïve participants. METHODS: A single-center, prospective study between October 2019 and November 2021 of adult participants with or without a planned surgical procedure. The reference standard was tolerance of medication tested during a procedure (NMBA-tolerant group) before ST. Participants received skin prick testing (SPT) and intradermal test (IDT) injections at 5-7 increasing concentrations of 1 or more medications. All medications were reconstituted according to package insert instructions and diluted with 0.9% saline. A concentration was considered irritant when more than 5% of participants had a positive test per ST positivity criteria (wheal ≥3 mm than initial wheal and associated erythema of the same size or greater than wheal). We also compared our results with current guidelines. RESULTS: A total of 187 participants (78% NMBA-tolerant) underwent 7812 skin tests. All undiluted SPT concentrations were nonirritant. We found the following maximal IDT NICs (mg/mL): cisatracurium (0.02), rocuronium (0.05), succinylcholine (0.8), vecuronium (0.01), neostigmine (0.2), sugammadex (50), and S-R-Cx (sugammadex 7.14 + rocuronium 2). CONCLUSION: Our results suggest that SPT may be performed with undiluted stock concentrations. We confirm maximal IDT NICs for cisatracurium and rocuronium. We also propose that currently recommended maximal IDT NICs of succinylcholine, neostigmine, sugammadex, and S-R-Cx could be increased, whereas the maximal IDT NIC of vecuronium could be decreased compared with current guidelines and prior reports.
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Bloqueo Neuromuscular , Bloqueantes Neuromusculares , Fármacos Neuromusculares no Despolarizantes , gamma-Ciclodextrinas , Adulto , Humanos , Sugammadex , Rocuronio , Bromuro de Vecuronio , Neostigmina , gamma-Ciclodextrinas/uso terapéutico , Succinilcolina , Estudios Prospectivos , Androstanoles , Bloqueo Neuromuscular/métodosRESUMEN
Perioperative hypersensitivity (POH) is an uncommon, potentially life-threatening event. Identification of POH can be difficult given the lack of familiarity, physiological effects of anesthesia, draping of the patient during surgery, and potential nonimmunological factors contributing to signs and symptoms. Given the unique nature and large number of medications administered in the perioperative setting, evaluation of POH can be challenging. In this paper, we present a practical approach to management with an emphasis on understanding what happens in the operating room, the overlap of signs and symptoms between nonimmunological and immunological reactions, acute management, and subsequent evaluation. In addition, we provide a strategy for further review of an initially negative evaluation and emphasize the importance of establishing management plans for the patient as well as providing recommendations to the medical, anesthesia, and surgical teams for future surgeries. A critical factor for successful management at all points in the process is a close collaboration between the anesthesia and the allergy teams.
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Anafilaxia , Anestesia , Hipersensibilidad a las Drogas , Humanos , Hipersensibilidad a las Drogas/diagnóstico , Hipersensibilidad a las Drogas/terapia , Anafilaxia/diagnósticoRESUMEN
Perioperative anaphylaxis (PA) is a rare but life-threatening condition that poses diagnostic and management challenges in the operating room. The incidence of severe perioperative reactions is estimated to be approximately 1:7000-10,000. Management involves both immediate stabilization of the patient and identifying the culprit agent. Identification is essential to prevent recurrence of the event in subsequent surgeries and to avoid unnecessary labeling of drug allergy. Identifying all possible exposures including medications, disinfectants, latex, and dyes and choosing the appropriate tests are essential for proper evaluation. To identify the culprit, primary testing modalities include tryptase at the time of the reaction with subsequent levels and skin testing with nonirritating concentrations to the medications and substances utilized during the procedure and those potentially used as alternates. This strategy provides guidance for future surgeries and procedures. Close collaboration between the allergy, anesthesiology, and surgery teams is essential for appropriate management of these patients at the time of the reaction, during the post event evaluation and in preparation for subsequent surgeries.
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Anafilaxia , Hipersensibilidad a las Drogas , Anafilaxia/diagnóstico , Anafilaxia/etiología , Anafilaxia/prevención & control , Hipersensibilidad a las Drogas/diagnóstico , Hipersensibilidad a las Drogas/epidemiología , Hipersensibilidad a las Drogas/terapia , Humanos , Pruebas Cutáneas/efectos adversos , TriptasasRESUMEN
Perioperative anaphylaxis is a potentially life-threatening and under-recognized event most commonly caused by antibiotics, neuromuscular blocking agents, dyes, latex, and disinfectants. This review provides updates in the epidemiology and pathogenesis of perioperative anaphylaxis, discusses culprit agents, and highlights the tenets of management including a comprehensive allergy evaluation.
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Anafilaxia , Hipersensibilidad a las Drogas , Bloqueantes Neuromusculares , Anafilaxia/diagnóstico , Anafilaxia/epidemiología , Anafilaxia/etiología , Antibacterianos , Hipersensibilidad a las Drogas/diagnóstico , Hipersensibilidad a las Drogas/epidemiología , Hipersensibilidad a las Drogas/terapia , Humanos , Bloqueantes Neuromusculares/efectos adversosAsunto(s)
Angioedema/inducido químicamente , Angioedema/epidemiología , Inhibidores de la Enzima Convertidora de Angiotensina/efectos adversos , Adulto , Negro o Afroamericano/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Estudios de Casos y Controles , Registros Electrónicos de Salud , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Factores de Riesgo , Atención Terciaria de Salud , Población Blanca/estadística & datos numéricos , Adulto JovenRESUMEN
Type I hypersensitivity reactions (HSR) to dabrafenib are rare but have been previously described. We present a case where a 72-year-old woman with recurrent, metastatic BRAF-mutated melanoma developed a type I HSR to dabrafenib. We, therefore, developed a desensitization protocol with encorafenib, a similar class agent, to allow the patient to continue with treatment. Patients with a history of HSR to dabrafenib may be considered for encorafenib desensitization when other therapeutic options are limited.
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Carbamatos/uso terapéutico , Melanoma/tratamiento farmacológico , Recurrencia Local de Neoplasia/tratamiento farmacológico , Neoplasias Cutáneas/tratamiento farmacológico , Sulfonamidas/uso terapéutico , Anciano , Carbamatos/farmacología , Femenino , Humanos , Melanoma/patología , Neoplasias Cutáneas/patología , Sulfonamidas/farmacologíaRESUMEN
BACKGROUND: The incidence of fatal and near-fatal outcomes after perioperative anaphylaxis is unknown in the USA. Previously identified risk factors of neuromuscular-blocker-induced fatal perioperative anaphylaxis include male sex, obesity, and use of beta blockers. We examined the incidence of fatal and near-fatal outcomes after perioperative anaphylaxis in the USA and the underlying risk factors using a large national database. METHODS: Using the Nationwide Inpatient Sample from 2005 to 2014, we identified cases of fatal and near-fatal perioperative anaphylaxis, defined as perioperative anaphylaxis cases complicated by respiratory or cardiac arrest, using the International Classification of Diseases, Ninth Revision, Clinical Modification codes. RESULTS: Amongst 5223 perioperative anaphylaxis cases, the proportion of near-fatal or fatal cases attributable to perioperative anaphylaxis was 7.0% (95% confidence interval [CI]: 6.2-7.7), with near-fatal perioperative anaphylaxis cases accounting for 5.0% (95% CI: 4.4-5.6%) and fatal cases accounting for 2.0% (95% CI: 1.5-2.5%) of cases overall. Thus, the incidence of fatal or near-fatal perioperative anaphylaxis is 1.26 in 100 000 procedures. Risk factors for fatal or near-fatal perioperative anaphylaxis include age (≥65 yr); undergoing a cardiac procedure; and comorbid conditions of weight loss, non-metastatic solid tumours, metastatic cancer, paralysis, coagulopathy, renal failure, congestive heart failure, fluid and electrolyte disorder, and neurological disorders. Individuals with near-fatal or fatal perioperative anaphylaxis reactions had increased lengths of stay and hospital costs compared with controls. CONCLUSIONS: The incidence of fatal or near-fatal perioperative anaphylaxis in the USA was 1.26 in 100 000 procedures. Risk factors for fatal or near-fatal outcomes include older age, cardiac procedures, and specific comorbidities.
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Anafilaxia/mortalidad , Complicaciones Intraoperatorias/mortalidad , Bloqueantes Neuromusculares/efectos adversos , Complicaciones Posoperatorias/mortalidad , Antagonistas Adrenérgicos beta/efectos adversos , Adulto , Anciano , Bases de Datos Factuales , Femenino , Humanos , Incidencia , Pacientes Internos/estadística & datos numéricos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Obesidad/complicaciones , Factores de Riesgo , Factores Sexuales , Estados UnidosRESUMEN
Hereditary angioedema (HAE) is a disease manifested by repeated episodes of localized submucosal or subcutaneous edematous episodes, potentially triggered by emotional stress, mechanical trauma, or intake of estrogens. We present our experience managing two parturients with HAE. Multidisciplinary care is essential for planning and executing the specialized care of these patients, and management included extensive planning among obstetric, anesthesiology, and allergy and immunology teams. Pregnancy has been shown to have a variable effect on triggering HAE episodes. First-line treatment includes C1 esterase inhibitor concentrate, which can also be used for prophylaxis in high-risk patients. Neuraxial analgesia is recommended to avoid general anesthesia and was established early in both individuals. Vaginal delivery was well tolerated without need for emergent treatment for angioedema symptoms.
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Anestésicos , Angioedemas Hereditarios , Angioedemas Hereditarios/tratamiento farmacológico , Proteína Inhibidora del Complemento C1 , Femenino , Humanos , EmbarazoRESUMEN
BACKGROUND: The estimated worldwide incidence of perioperative or periprocedural anaphylaxis (PA) is between 1 in 1250 and 1 in 20,000 procedures. OBJECTIVE: To evaluate the incidence of PA in the United States and compare patient characteristics and underlying risk factors using a large national database. METHODS: Using deidentified data from the nationwide inpatient sample from 2005 to 2014, we identified cases of PA through the International Classification of Diseases, Ninth Revision, Clinical Modification codes and conducted a retrospective analysis. RESULTS: Among 35,647,347 surgeries and procedures, there were 5458 (0.015%) PA cases identified. The incidence of PA was 15.3 cases per 100,000 procedures. When compared with controls, PA cases had an increased mortality (3.4% vs 1.4%; P < .001), median length of stay (5 vs 3 days; P < .001), and median hospital cost ($45,155 vs $24,734; P < .001). The age group between 18 and 34 years (odds ratio [OR], 1.34; 95% confidence interval [CI], 1.13-1.58; P < .001) and female sex (OR, 1.40; 95% CI, 1.31-1.49; P < .001) were associated with increased odds of PA. Transplant (OR, 3.35; 95% CI, 2.59-4.34; P < .001), hematologic (OR, 1.63; 95% CI, 1.30-2.05; P < .001), vascular (OR, 1.49; 95% CI, 1.30-1.67; P < .001), and cardiac (OR, 1.47; 95% CI, 1.30-1.67; P < .001) procedures were at increased risk for PA. Several comorbidities were associated with PA including chronic pulmonary disease (OR, 1.41; 95% CI, 1.31-1.51; P < .001). CONCLUSION: The incidence of PA is 1 in 6531 procedures, with a mortality of 1 in 191,652 procedures. PA has worsening outcomes compared with controls. The risk factors of PA include age, sex, procedure type, and comorbidities.
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Anafilaxia/epidemiología , Periodo Perioperatorio , Procedimientos Quirúrgicos Operativos , Adolescente , Adulto , Anciano , Comorbilidad , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Factores de Riesgo , Estados Unidos , Adulto JovenRESUMEN
OBJECTIVES: Rituximab (RTX) treatment is used for antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis, but its benefits in eosinophilic granulomatosis with polyangiitis (EGPA) are unclear. Our aim was to characterize asthma control and glucocorticoid (GC) sparing after RTX treatment. METHODS: A retrospective, computer-assisted search was performed to identify patients with EGPA and GC-dependent asthma diagnosed between 2000 and 2017 who received RTX for remission induction. Demographic and clinical features were analyzed. RESULTS: Of the 17 patients included, the majority were myeloperoxidase-ANCA positive (n = 13, 76.5%). Uncontrolled asthma symptoms and atopy were present in 13 patients (76.5%). RTX was used for initial remission induction in patients with new onset of severe disease (n = 5, 29.4%) and after failed remission induction with other immunosuppression (n = 12, 70.6%). It was used for remission maintenance in nine patients (52.9%). GCs were used for maintenance at a median dose of 25 mg/day (interquartile range, 16.25-37.5). At the end of follow-up, 13 patients (76.5%) had non-severe or controlled asthma, and remission was achieved in 12 (70.6%). Median serum eosinophil and C-reactive protein values decreased (1.06 vs 0.10 × 109/L [P = .012] and 27.0 vs 5.0 mg/dL [P = .001], respectively), whereas pulmonary function test results remained unchanged. Median GC dose was significantly reduced at 6, 12, 18, and 24 months (P < .0001). Patients receiving RTX for maintenance required less than 10 mg of GCs for asthma control. CONCLUSION: RTX seems to be safe and have GC-sparing efficacy for asthma control in EGPA. Randomized controlled trials are needed for detailed study of RTX for treating EGPA.Key Points⢠In this retrospective study we have concluded that rituximab (RTX) might be considered for the control of severe corticosteroid-dependent asthma in eosinophilic granulomatosis polyangiitis (EGPA) patients especially when myeloperoxidase antibodies are positive.⢠Rituximab has not been studied particularly for asthma control in EGPA patients.⢠The most noticeable effect of RTX was the decrease in the use of corticosteroids for the control of asthma.
Asunto(s)
Vasculitis Asociada a Anticuerpos Citoplasmáticos Antineutrófilos/tratamiento farmacológico , Asma/tratamiento farmacológico , Glucocorticoides/uso terapéutico , Rituximab/uso terapéutico , Anciano , Vasculitis Asociada a Anticuerpos Citoplasmáticos Antineutrófilos/sangre , Anticuerpos Anticitoplasma de Neutrófilos/sangre , Proteína C-Reactiva/metabolismo , Eosinófilos/metabolismo , Femenino , Humanos , Masculino , Persona de Mediana Edad , Recurrencia , Inducción de Remisión , Estudios RetrospectivosRESUMEN
The authors present a case of a patient with multiple episodes of perioperative anaphylaxis. The incidence and the most common causes of perioperative anaphylaxis are reviewed. The most common causes can vary by country and the type of perioperative medications used. The unique environment and the multiple medications and substances used in the anesthesia and surgical setting that make a definitive diagnosis challenging are outlined. A systematic strategy to recognize the reaction, identify the culprit, and direct future management are demonstrated. Management of the patient experiencing perioperative anaphylaxis requires close collaboration between the anesthesia, surgical, and allergy teams.
Asunto(s)
Anafilaxia/inducido químicamente , Antiinfecciosos Locales/efectos adversos , Clorhexidina/efectos adversos , Hipersensibilidad a las Drogas/diagnóstico , Periodo Perioperatorio , Anciano , Manejo de la Vía Aérea , Analgésicos Opioides/efectos adversos , Anafilaxia/metabolismo , Anafilaxia/terapia , Antibacterianos/efectos adversos , Profilaxis Antibiótica , Bacitracina/efectos adversos , Broncodilatadores/uso terapéutico , Coloides/efectos adversos , Colorantes/efectos adversos , Hipersensibilidad a las Drogas/etiología , Hipersensibilidad a las Drogas/metabolismo , Epinefrina/uso terapéutico , Fluidoterapia , Glucocorticoides/uso terapéutico , Humanos , Hipnóticos y Sedantes/efectos adversos , Inmunoglobulina E/metabolismo , Pruebas Intradérmicas , Hipersensibilidad al Látex/diagnóstico , Masculino , Bloqueantes Neuromusculares/efectos adversos , Terapia por Inhalación de Oxígeno , Povidona Yodada/efectos adversos , Recurrencia , Pruebas Cutáneas , Sugammadex/efectos adversos , Simpatomiméticos/uso terapéutico , Reacción a la Transfusión , Triptasas/metabolismoRESUMEN
Suspected perioperative allergic reactions are rare but can be life-threatening. The diagnosis is difficult to make in the perioperative setting, but prompt recognition and correct treatment is necessary to ensure a good outcome. A group of 26 international experts in perioperative allergy (anaesthesiologists, allergists, and immunologists) contributed to a modified Delphi consensus process, which covered areas such as differential diagnosis, management during and after anaphylaxis, allergy investigations, and plans for a subsequent anaesthetic. They were asked to rank the appropriateness of statements related to the immediate management of suspected perioperative allergic reactions. Statements were selected to represent areas where there is a lack of consensus in existing guidelines, such as dosing of epinephrine and fluids, the management of impending cardiac arrest, and reactions refractory to standard treatment. The results of the modified Delphi consensus process have been included in the recommendations on the management of suspected perioperative allergic reactions. This paper provides anaesthetists with an overview of relevant knowledge on the immediate and postoperative management of suspected perioperative allergic reactions based on current literature and expert opinion. In addition, it provides practical advice and recommendations in areas where consensus has been lacking in existing guidelines.