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 Table of Contents  
CASE REPORTS
Year : 2021  |  Volume : 9  |  Issue : 4  |  Page : 146-148

Perioperative allergy and anaphylaxis: An anesthesiologist’s nightmare


Department of Anaesthesiology, NH-SRCC Children’s Hospital, Mumbai, Maharashtra, India

Date of Submission02-Jul-2021
Date of Acceptance11-Oct-2021
Date of Web Publication15-Jul-2022

Correspondence Address:
Priyanka Pradeep Karnik
Department of Anaesthesiology, NH-SRCC Children’s Hospital, B-2, 401, Rutu Park, Near Vrindavan Society, Thane west, KeshavraoKhadyeMarg, Mahalakshmi, Mumbai 400034, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/dypj.DYPJ_39_21

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  Abstract 

Perioperative anaphylactic reactions though rarer than in adults, result in severe morbidity in children. There is a shift in the most commonly implicated agents causing anaphylaxis from neuromuscular blocking agents and latex to antibiotics. The allergy work up for children can be tedious due to the necessity to perform skin prick tests which are the gold standard. Anaesthesia for children with documented hypersensitivity to various foodstuffs and drugs can be fraught with difficulties due to airway hyperreactivity, need to avoid culprit drugs and possibility of biphasic reaction if epinephrine is not administered on time. We describe perioperative management of three cases with history of allergies and their implications.

Keywords: Anaphylaxis, children, neuromuscular blocking agents, perioperative


How to cite this article:
Karnik PP, Shah HB, Dave NM, Rawlani SS. Perioperative allergy and anaphylaxis: An anesthesiologist’s nightmare. D Y Patil J Health Sci 2021;9:146-8

How to cite this URL:
Karnik PP, Shah HB, Dave NM, Rawlani SS. Perioperative allergy and anaphylaxis: An anesthesiologist’s nightmare. D Y Patil J Health Sci [serial online] 2021 [cited 2022 Aug 8];9:146-8. Available from: http://www.dypatiljhs.com/text.asp?2021/9/4/146/351081




  Introduction Top


Perioperative allergic and anaphylactic reactions are an important cause of morbidity and even mortality during anesthesia. Patients are exposed to a large number of substances including drugs, dyes, cleaning solutions, and latex, which can act as triggers for hypersensitivity reactions. Under anesthesia, initial signs of such reactions may go unnoticed and may progress to severe respiratory and cardiovascular manifestations.[1],[2] We present three cases with a history of allergic reactions and discuss the anesthesia implications of such cases.


  Case Report Top


An 11-year-old, weighing 29 kg, child with a history of seizures and right-sided hemiparesis was posted for left hemispherotomy. After routine anesthesia induction and intubation, arterial line was secured. The blood loss started gradually during dissection around the cortical veins which increased leading to hypotension. Gelofusine was started to replace the loss. The surgeon covered the surface of brain with patties soaked with hemostatic agent feracrylum. Suddenly there was a fall in the blood pressure from systolic 80 mm Hg to 60 mm Hg and the airway pressure increased from 17 to 35 cm of H2O. External causes of increased airway pressures like tube kinking, displacement, and secretions were ruled out. The patient was placed in Durant’s position suspecting VAE, field irrigated with normal saline and Noradrenaline started. After no response, 0.1 mL/kg of 1:10000 of Adrenaline was given intravenously. There was a drastic reduction in airway pressures from 35 to 19 cm of H2O within seconds of Adrenaline administration along with an increase in blood pressure. Ten minutes later there was a resurge in airway pressures to 34 cm of H2O which responded to the second bolus of adrenaline. Adrenaline infusion at 0.05 mcg/kg/min was started. The patient stabilized and the remainder of surgery was uneventful. Serum IgE levels were sent which came out to be high (238 IU/mL, normal range: 11–172).

Two and half year old patient, weighing 10.5 kg, known case of atopic dermatitis was posted for MRI spine in view of difficulty in walking since 2–3 months. The patient was allergic to eggs, cow’s milk, fish, wheat, banana, kiwi, animal dander, and dust with total IgE antibody count of 2588 Ku/L (normal value: 0–16.2). Allergic testing to drugs had not been conducted. The child was anaesthetized with sevoflurane and intravenous line was secured. Inj. midazolam 0.05 mg/kg, glycopyrrolate 4µg/kg, and ketamine 1 mg/kg was given. Oxygen at 2 L/min was administered via nasal prongs. The child had an episode of desaturation due to laryngospasm during the procedure which required Inj. succinylcholine 0.5 mg/kg. There were no cutaneous signs of anaphylaxis. Inj. hydrocortisone 2 mg/kg was given intravenously and breathing was supported using Jackson Rees circuit. The child was observed in the emergency room for over 6 h.

A 9-year-old girl, weighing 30 kg, was posted for right hip arthrotomy with arthrolysis for hip movement restriction. She had a recent episode of severe allergic reaction to naproxen resulting in swelling of face and lips [Figure 1]A, which had subsided with oral fexofenadine [Figure 1]B. Her allergen screening test concluded that she is allergic to ibuprofen, ciprofloxacin, ofloxacin, and nimesulide among drugs and negative for eggs and xylocaine. Preoperative intradermal sensitivity testing for bupivacaine 0.25% was negative. Anesthesia was induced with propofol 3 mg/kg. Muscle relaxants were avoided and 2.5 size i-gel was inserted. Anesthesia was maintained using oxygen, air, and sevoflurane. Epidural single-shot injection was given using 0.5 mL/kg of bupivacaine 0.25% with Inj. clonidine 2 µg/kg. Perioperative course was uneventful and child was observed in post anesthesia care unit. As there was no testing done for common anesthesia drugs, adrenaline 0.1 mg/mL and 0.01 mg/mL were kept ready along with chlorpheniramine, hydrocortisone, and dexamethasone for the above two cases.
Figure 1: Swelling of face in the child: (A) after naproxen and (B) subsiding after fexofenadine

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  Discussion Top


The estimated incidence of perioperative anaphylaxis found in the 6th National Audit Project (NAP6) survey in the UK was ≈1:10,000 anesthetics in adults and 1:37000 in children but the actual incidence may be higher due to unreported cases.[3] The Ring and Messmer grading scale is the tool used most widely to describe clinical phenotypes. Grades I(mucocutaneous signs) and II (moderate multivisceral signs) reactions are not life-threatening, whereas Grades III and IV are life-threatening IgE mediated conditions leading to even cardiac arrest.[4] Pre-anesthesia assessment of every child must include the history of allergy to drug and foodstuffs(breathing difficulty, rash, redness after drug exposure) and adverse events during previous anesthesia exposures.

Investigation of pediatric allergy is difficult. Serum-specific IgE assays are available for a few drugs including suxamethonium, antibiotics (e.g. amoxicillin), morphine, chlorhexidine, protamine, and NMBAs. Skin prick testing and intradermal tests are gold standard for detection of possible provocative agents. A 4–6-week interval is required between the reaction and the skin test to avoid false-negative reaction due to mast cell depletion.

The NAP6 found antibiotics to be the most commonly implicated agents for anaphylactic reactions followed by neuromuscular blocking agents (NMBAs), chlorhexidine, and patent blue dye. Other agents included gelatins, blood products, ondansetron, protamine, ibuprofen, and propofol. The Wake Up Safe database also showed antibiotics to be the most common agents in children followed by NMBAs and opioid analgesics.[5] Allergy to gelatin has been associated with anaphylactic reactions to measles–mumps–rubella (MMR) vaccination and occurs within 10 min of starting the infusion. In the first scenario, the anaphylactic reaction occurred 30 min after starting gelofusine. Though latex allergy is rarely seen nowadays, there exists an association of latex allergy and allergy to plant-derived foods like kiwi, peach, avocado, tomato, and banana, called a latex-fruit syndrome.[6],[7] So a history of allergy to these fruits and previous exposure to latex during surgery should prompt us to take necessary precautions to avert an anaphylactic reaction. Chemicals in toothpastes, shampoos, and cough syrups with codeine contain quaternary ammonium ion (QAI) groups which may cause sensitization to NMBAs. Anaphylaxis to local anesthetics is very uncommon and has decreased in frequency because of the decreased use of the ester group of local anesthetics. Most allergic reactions are due to the common metabolic product of the ester local an aesthetic, para-aminobenzoic acid.[7] Allergic reaction to propofol is extremely rare. Recent evidence shows that there is no need to withhold propofol in patients allergic to egg, soy, or peanut.[8],[9] Fish allergy has been implicated as a risk factor for protamine anaphylaxis, as protamine is traditionally extracted from the sperm of fish.

Most hypersensitivity reactions occur immediately after induction but some may take place during intubation, positioning, transfer, or emergence. Bronchospasm and high airway pressures are the most common presenting feature in children. In our second report, a history of atopic dermatitis and food allergies might have contributed to a reactive airway and culminated in laryngospasm. In case of a severe allergic reaction, it may be prudent to postpone elective surgery. Emergency surgery should not be delayed and necessary precautions should be taken to avoid culprit agents. In patients with a history of anaphylaxis, regional anesthesia should be considered wherever possible. Drugs, like ketamine, midazolam, etomidate, and dexmedetomidine, with very rare risk of hypersensitivity reactions should be used. Inhalational anesthetics can be safely used. Patient should be premedicated with steroids and antihistaminics. Emergency drugs should be available in the operation theatre. Adrenaline 0.01 mg/kg of 1:1000 solution given intramuscularly is the first-line therapy in Grade 3 and 4 reactions. Volume loading, corticosteroids, and beta 2 agonists, and vasopressors are adjunctive therapies, whereas antihistaminics are for cutaneous signs. Patients experiencing resolution of symptoms while in hospital should be observed for a minimum of 4–6 h before discharge to monitor for a biphasic reaction.[10]


  Conclusion Top


Anaphylaxis management protocols should be set and treatment appropriate for children should be immediately available wherever pediatric anesthesia is administered. All anesthesiologists administering anesthesia to children should be trained in the management of pediatric anaphylaxis either in simulation or perioperative life support workshops.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Lieberman P Anaphylactic reactions during surgical and medical procedures. J Allergy Clin Immunol 2002;110:S64-9.  Back to cited text no. 1
    
2.
Hepner DL, Castells MC Anaphylaxis during the perioperative period. Anesth Analg 2003;97:1381-95.  Back to cited text no. 2
    
3.
Harper NJN, Cook TM, Garcez T, Farmer L, Floss K, Marinho S, et al. Anaesthesia, surgery, and life-threatening allergic reactions: epidemiology and clinical features of perioperative anaphylaxis in the 6th national audit project (NAP6). Br J Anaesth 2018;121:159-71.  Back to cited text no. 3
    
4.
Khaleva E, Franz A, Garvey LH, Jay N, Ylescupidez A, Bahnson HT, et al. Perioperative anaphylaxis in children: Etiology, time sequence, and patterns of clinical reactivity. Pediatr Allergy Immunol2020;31:85-94.  Back to cited text no. 4
    
5.
Wakimoto M, Miller R, Kim SS, Uffman JC, Nafius OO et al. Perioperative anaphylaxis in children: A report from the Wake-Up Safe collaborative. Pediatr Anaesth 2021;31:205-12.  Back to cited text no. 5
    
6.
Calamelli E, Piccinno V, Giannetti A et al. Latex-fruit syndrome and degree of severity of natural rubber latex allergy: Is there a link?. Clin Transl Allergy 2011;1:O18.  Back to cited text no. 6
    
7.
Dewachter P, Mouton-Faivre C, Emala CW Anaphylaxis and anesthesia: Controversies and new insights. Anesthesiology 2009;111:1141-50.  Back to cited text no. 7
    
8.
Bagley L, Kordun A, Sinnott S, Lobo K, Cravero J Food allergy history and reaction to propofol administration in a large pediatric population. Paediatr Anaesth 2021;31:570-7.  Back to cited text no. 8
    
9.
Asserhøj LL, Mosbech H, Krøigaard M, Garvey LH No evidence for contraindications to the use of propofol in adults allergic to egg, soy or peanut†. Br J Anaesth 2016;116:77-82.  Back to cited text no. 9
    
10.
Cheng A Emergency treatment of anaphylaxis in infants and children. Paediatr Child Health 2011;16:35-40.  Back to cited text no. 10
    


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