Management of a surgical patient with a label of penicillin allergy: narrative review and consensus recommendations.

Unsubstantiated penicillin-allergy labels are common in surgical patients, and can lead to significant harm through avoidance of best first-line prophylaxis of surgical site infections and increased infection with resistant bacterial strains. Up to 98% of penicillin-allergy labels are incorrect when tested. Because of the scarcity of trained allergists in all healthcare systems, only a minority of surgical patients have the opportunity to undergo testing and de-labelling before surgery. Testing pathways can be modified and shortened in selected patients. A variety of healthcare professionals can, with appropriate training and in collaboration with allergists, provide testing for selected patients. We review how patients might be assessed, the appropriate testing strategies that can be used, and the minimum standards of safe testing.

Consensus clinical scoring for suspected perioperative immediate hypersensitivity reactions.

BACKGROUND: Grading schemes for severity of suspected allergic reactions have been applied to the perioperative setting, but there is no scoring system that estimates the likelihood that the reaction is an immediate hypersensitivity reaction. Such a score would be useful in evaluating current and proposed tests for the diagnosis of suspected perioperative immediate hypersensitivity reactions and culprit agents. METHODS: We conducted a Delphi consensus process involving a panel of 25 international multidisciplinary experts in suspected perioperative allergy. Items were ranked according to appropriateness (on a scale of 1-9) and consensus, which informed development of a clinical scoring system. The scoring system was assessed by comparing scores generated for a series of clinical scenarios against ratings of panel members. Supplementary scores for mast cell tryptase were generated. RESULTS: Two rounds of the Delphi process achieved stopping criteria for all statements. From an initial 60 statements, 43 were rated appropriate (median score 7 or more) and met agreement criteria (disagreement index <0.5); these were used in the clinical scoring system. The rating of clinical scenarios supported the validity of the scoring system. Although there was variability in the interpretation of changes in mast cell tryptase by the panel, we were able to include supplementary scores for mast cell tryptase. CONCLUSION: We used a robust consensus development process to devise a clinical scoring system for suspected perioperative immediate hypersensitivity reactions. This will enable objectivity and uniformity in the assessment of the sensitivity of diagnostic tests.

Passive transient transfer of peanut allergy by liver transplantation.

We report a case of transient symptomatic transferred IgE-mediated peanut allergy after elective blood-group compatible liver transplantation. We show that the allergy was transient and therefore passive, authorizing further uneventful peanut consumption. Skin tests with commercial peanut extract and native peanut were performed in the recipient. Circulating specific IgE against peanut and recombinant peanut allergens (rArah1, rArah2, rArah3) was measured in stored serum samples collected from the recipient between 6 months before and 8 months after liver transplantation. Specific IgE levels in the donor were measured at the time of multiorgan donation. In the recipient, diagnosis of IgE-mediated peanut anaphylaxis was based on the clinical history and detection of specific IgE against peanut and recombinant major peanut allergens (rArah1, rArah2 and rArah3). Skin tests were negative and specific IgE undetectable 6 months after the clinical reaction. Oral peanut challenge was negative excluding persistent peanut allergy. This case confirms that IgE-mediated peanut allergy can be transferred by liver transplantation and shows that it may be transient and therefore passively acquired.

Anaphylactic reaction after methylene blue-treated plasma transfusion.

Methylene blue-treated fresh-frozen plasma (MB-FFP) is mainly used in Europe. The advantage of the methylene blue system is that units can be treated individually. The combined action of methylene blue and illumination is a photodynamic process preventing viral RNA and DNA replication. We report the first immediate allergic hypersensitivity reaction to methylene blue-treated plasma transfusion. The clinical course and subsequent assessment of the allergic reaction, including skin tests and basophil activation test, confirmed methylene blue-induced IgE-mediated anaphylaxis. All immediate reactions after MB-FFP transfusion should be investigated to document the underlying mechanism.

An anaphylactic reaction to transdermal delivered fentanyl.

Immediate allergic hypersensitivity reactions with fentanyl are rarely reported. We diagnosed a presumably IgE-mediated allergic hypersensitivity reaction comprising generalized erythema and bronchospasm 4 h after the first-time application of transdermal fentanyl. Prick test remained negative with fentanyl whereas an intradermal test (IDT) with fentanyl was positive (dilution 10(-2)). Cross-reactivity was found with sufentanil but not with remifentanil. The diagnosis was supported by the clinical history and a positive IDT with fentanyl. This case report confirms the need for a systematic allergological investigation in case of immediate hypersensitivity reactions for all drugs and all modes of administration.

[Immediate allergy to iodinated contrast agents and prevention of reactions]. / Allergie immédiate aux produits de contraste iodés et prévention des réactions.

The incidence and morbimortality of immediate hypersensitivity reactions following iodinated contrast media (ICM) injection remain unknown. The diagnosis of an immediate hypersensitivity reaction relies on a triad associating the precise description of the initial clinical manifestations and their delay of onset, the results of the biological assessment performed after the reaction including histamine and tryptase serum level measurements, and the results of skin testing with the culprit agent. Analysis of these data allows identification of the pathophysiologic mechanism of the reaction and the allergen involved in case of allergic hypersensitivity. Skin tests should be performed according to strict criteria. Cross-reactivity with ICM has to be investigated in order to propose a nonreactive ICM for future procedures. Allergic hypersensitivity to a given ICM imposes its definitive avoidance but not the avoidance of all iodinated drugs. The allergenic sequence has not yet been identified but is not the iodine atom itself. Asthma and treatment with beta-blockers are not risk factors of immediate allergic reactions to ICM per se, but may increase their severity. The various published protocols of premedication do not prevent the occurrence of an allergic/anaphylactic reaction to an ICM. The avoidance of the culprit ICM is the only way to prevent further reactions.

["Iodine allergy": point of view]. / Allergie à l'iode: le point sur la question.

OBJECTIVE: The aim of this literature review is to suggest a diagnostic and a preventive attitude in patients having presented an immediate hypersensitivity reaction due to an iodinated drug. DATA SOURCES: Literature review. Data were searched in the Medline database from 1967 to 2004 in English and French language. Complementary references were selected from the bibliography of selected references or from authors' personal databases. The following key-words were used separately or combined: Hypersensitivity, Immediate; Allergy; Contrast Media; Povidone-Iodine; Iodine; Iodine Compounds; Iodides; Amiodarone; Seafood, Parvalbumins; Tropomyosin. STUDY SELECTION: Randomized studies, epidemiological studies, original articles, clinical cases, and letters to the editor were selected. DATA SYNTHESIS: The implication of iodine has never been demonstrated during allergic hypersensitivity reactions due to iodinated drugs. However, IgE-mediated allergic hypersensitivity reactions have been published with contrast media or iodinated antiseptics and will be described in this development. In a wider sense, allergic hypersensitivity reactions due to seafood are evoked because often improperly considered as a risk factor of allergic reaction to iodinated drugs. The allergenic determinant responsible of patient sensitization is not known for iodinated contrast media, but is probably due to povidone in case of iodine povidone. In fish, the allergen is described as the protein M. There has also been strong immunological evidence that tropomyosin is a cross-reactive allergen among crustaceans and molluscs (shellfishs). In case of hypersensitivity reaction occurring with iodinated drug, an allergological assessment is required to confirm the immune mechanism, to identify the culprit drug or substance and to identify cross-reactivity especially with iodinated contrast media. CONCLUSION: Asking a patient if he/she is "allergic to iodine" is a question that should be avoided because its significance is null. A diagnosis of drug allergy, essentially relying on clinical symptoms, biological tests and cutaneous tests, is required to take adequate preventive measures.

[Value of skin tests for the choice of a neuromuscular blocking agent after an anaphylactic reaction]. / Intérêt des tests cutanés pour le choix d'un curare après une réaction anaphylactique.

We report a grade III allergic hypersensitivity reaction occurring in a 72-year-old patient immediately after anaesthesia induction. Anaphylaxis to cisatracurium was diagnosed on clinical symptoms, biological tests and positivity of the cutaneous tests to this neuromuscular blocking agent. Five days after this allergological assessment, rocuronium, a muscle relaxant for which skin tests appeared negative was used during surgery without adverse effects. The authors underline the value of a detailed allergological assessment to identify the pathophysiologic mechanism, the culprit drug and to propose a safer alternate drug that might be used.

[Prevention of severe reactions after iodinated contrast media injection: review of the literature]. / Prévention des réactions sévères après injection de produits de contraste iodés: revue de la littérature.

One of the goal of a premedication before contrast agent injection is to decrease their adverse effects. However, no randomized study was published to date on the value of a systematic premedication for the prevention of immediate severe reactions. A knowledge of pathophysiological mechanisms and patients at risk seems to be essential. The allergic mechanism is probably one of the etiologic diagnosis, but this hypothesis needs to be confirmed by a multicenter prospective study. A patient who has had previous allergic reaction with contrast agent should undergo intradermal tests so as to identify and eliminate the culprit contrast medium in order to avoid any subsequent allergic accidents. Indeed, measurement of specific IgEs has not been validated for contrast media. The test dose should be discarded because it is a false security. The eventuality of adverse effects of the drugs used for premedication should not be underestimated.

[Severe reactions to iodinated contrast agents: is anaphylaxis responsible?]. / Réactions sévères avec les produits de contraste iodés: l'anaphylaxie est-elle responsable?

PURPOSE: The etiology of severe reactions following injection of iodinated contrast agents is the subject of controversy. No consensus has been established regarding the management of patients at risk, risk factors and premedication because in most cases published no diagnostic exploration has been carried out on patients who have experienced a severe reaction. MATERIAL: and Methods. Diagnosis of drug anaphylaxis is based on clinical history, proof of mediator release and drug-specific IgE antibodies (when the technique is available) or cutaneous tests (when direct technique is not available). RESULTS: This approach has been adopted for etiologic diagnosis of 5 clinical cases of severe anaphylactoid reactions (including one death) following the injection of ionic and non ionic contrast agents. Clinical symptoms, biology and cutaneous tests are consistent with anaphylaxis. CONCLUSION: Any patient who has had a severe anaphylactoid reaction following injection of a contrast agent should undergo an allergological assessment to confirm the diagnosis and identify the culprit contrast agent. Indeed, no premedication has proved efficient for the prevention of subsequent allergic reactions.

[Allergic risk of aprotinin]. / Le risque allergique de l'aprotinine.

OBJECTIVE: To analyse the risk of anaphylactic reaction with the administration of aprotinin, either by i.v. route or as a biological sealant application and to propose updated guidelines in accordance with current data of the literature. DATA SOURCES: Search in the Medline data base of articles in French, English and German, published since 1960, using following key words: aprotinin, allergy, anaphylaxis. STUDY SELECTION: All categories of articles on this topic have been selected. DATA EXTRACTION: Articles have been analysed for history, incidence and mechanisms of anaphylactic reactions, symptomatology, factors of risk, diagnosis and precautions of use. DATA SYNTHESIS: Aprotinin is widely used for decreasing preoperative bleeding, especially in cardiac and orthopaedic surgery. This heterologue protein can cause anaphylactic reactions in 0.5 to 5.8% of patients, depending of the inclusion criteria. They are mediated by IgG and IgE antibodies. Aprotinin has also a direct, non specific, histaminoliberation effect. The clinical presentation includes various degrees of severity, up to cardiac arrest. Documented factors of risk are a previous parotinin administration, 15 days to 6 months before, and intolerance to beef meat, white of egg, cheese and milk. The immediate biological diagnosis is obtained on assessing the degranulation of basophiles (histamine) and mastocytes (tryptase), as well as the concentration of anti-aprotinin antibodies (RAST IgE), with a test of inhibition. The secondary assessment, six weeks later, includes prick-tests and intradermoreactions if the former are negative. The mean precaution consists to search factors of risk at preanaesthetic assessment. The predictive value of systematic prick-tests has not yet been validated. Anti H1 and anti H2 premedication is inefficient. A test dose can trigger a severe reaction. CONCLUSION: Considering a significant anaphylactic risk, aprotinin administration becomes only licit after a careful evaluation of the benefit-risk ratio.

[In vivo rheologic studies of plasma substitutes]. / Effets rhéologiques in vivo des substituts plasmatiques.

The aim of this study was to compare in 60 ASA1 patients, the rheological effects of a 500 ml plasma substitute infusion at induction of general anaesthesia. The 60 patients were allocated into 6 groups of 10. Each group received either albumin 4%, or dextran 40 3.5%, or dextran 60 6%, or hydroxyethylstarch (HES) 200 6%, or modified fluid gelatin or Ringer lactate. The infusion extended over 30 minutes. In blood samples obtained before infusion, immediately after the end, three and 24 hours after the end of infusion, osmotic pressure, oncotic pressure, proteins and fibrinogen concentration were measured. Following rheological parameters were also assessed: plasma viscosity, blood viscosity at two shear rates (0.5 and 128 s-1), erythrocyte aggregation by primary and final aggregation times as well as total and partial dissociation thresholds. The determinations were carried out at haematocrit corrected to 40%. At intergroup analysis of the different substitutes compared to albumin 4%, with the exception of Ringer lactate, there was no significant modification of osmotic and oncotic pressures or fibrinogen concentrations. Only gelatin and dextran 60 modified the rheological parameters. The intragroup comparison did not demonstrate significant variations of osmotic and oncotic pressures. Fibrinogen concentrations remained unchanged up to the 24th hours, where they increased as a reaction to surgery. Similar changes of rheological parameters occurred for Ringer lactate, albumin 4% and dextran 40: decrease of plasma viscosity (< 10%) and blood viscosity (< 20% at shear rate of 0.5 s-1), increase of primary aggregation time (30-50%) with decrease of total dissociation threshold (10-20%). These changes ended 24 hours after infusion. Dextran 60 and gelatin elicited a modification of blood rheology until the 24th hour after the end of infusion. Such modifications did not occur with HES. It is concluded that when a rheological effect is required albumin 4% or dextran 40 3.5% should be used.

[The reduction of anesthetic risk by high frequency jet ventilation during endobronchial cryotherapy]. / Réduction du risque anesthésique par la jet ventilation à haute fréquence lors de la cryothérapie endobronchique.

Endotracheal cryotherapy was performed in 22 ASA III or IV patients with inoperable carcinoma. All patients received propofol by continuous infusion and fentanyl by bolus. In 11 patients (SV group) ventilation remained spontaneous. In 11 patients (HFJV group) high frequency jet ventilation was used with air-CO2 (1:1). Respiratory and haemodynamic parameters were studied and compared in the two groups. Systolic blood pressure was slightly and transiently lower in the HFJV group. In this group PaCO2 remained excellent during the whole procedure, in SV group hypoxemia was constant. PaCO2 increased in both groups but very shortly in the HFJV group. Several arrhythmias and other transient adverse effects occurred in the SV group, none in the HFJV group. Thus clinical and haemodynamic tolerance of HFJV seem excellent. HFJV appears to be a very secure method for difficult endoscopic procedures.

[Cardiovascular adverse effects due to phenylephrine eye drops in ophtalmic surgery]. / Effets indésirables cardiovasculaires des collyres à la phényléphrine en chirurgie ophtalmologique.

Adverse systemic reactions such as cardiovascular effects may occur following topical ocular application of phenylephrine. We report the case of a 49-year-old woman who, following topical application of phenylephrine eyedrops, experienced hypertension with electrocardiographic modifications and a rise in cardiac troponin Ic.