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HISTORY
The term anaphylaxis was coined by PORTER AND RICHET in 1902 In greek prophylaxis means protection, ANAPHYLAXIS means opposite protection Anaphylaxis generally occurs on re-exposure to a specific antigen and requires the release of proinflammatory mediators but it can also occur on first exposure because of cross reactivity among commercial products and drugs .
hypersenstivity reaction TYPE 2 reactions involve IgG Ig M and complement mediated cytotoxicity TYPE 3 REACTIONS involve immune complex formation and deposition leads to tissue damage TYPE 4 reactions are delayed type hypersenstivity reactions
ANAPHYLACTOID REACTIONS
ANAPHYLACTOID REACTIONS occur through a
direct nonimmune mediated reaction via release of mediators from mast cells and basophils but they present with symptoms similar to those of anaphylaxis
SCOPE
Prevalence and incidence
PREVALENCE
IT IS Difficult to determine incidence and prevalence
of anaphy. Acc. To an estimate it is 1 in 3500 to 1 in 13000 Mortality 3-6 % Multiple drugs are administered during anesthesia And because patients are under drapes early cutaneous symptoms are often unrecognized no available diagnostic test with absolute accuracy NMBA usually result skin test +ve for long time
CLINICAL HISTORY
1.Extent of sign of anaphylaxis
onset of symptom 4. Previous allergies from drugs or related compounds 5. underlying conditions
perioperative anaphylaxis is characterized by cardiovascular manifestation (73.6%),cutaneous symptoms (69.6%),and bronchospasm (44.2%) of cases.
administration but may occur in second NRL and antiseptics exhibit more delay onset and generally occur in maintenance anesthesia or recovery room Colloid may cause immediate reaction or delay onset
5.Underlying conditions
identified underlying condition can also help
to identify causative compounds Atopic individual are at the risk of anaphylaxis from NRL Mastocytosis,
CLINICAL FEATURES
Cutaneous sym.
Flushing ,pruritus urticaria ,angioedema G.it. Sym. Nausea ,vomitting ,abdominal cramps ,diarrhoea Absent or difficult to differentiate in general anesthesia , may be present in regional anesthesia or M.A.C. Respiratory sym. rhinitis ,laryngeal edema,shortness of breath,wheezing,respiratory arrest
i
Increased peak inspiratory pressure, increased end
tidal carbon dioxide ,decreased oxygen saturation,wheezing,bronchospasm CARDIOVASCULAR SYM. Tachycardia ,hypotension,cardiac arrythmias , cardiovascular collapse RENAL SYM. Decreased Urine output HEMATOLOGIC SYM. D.I.C.
PATHOPHYSIOLOGY
On initial exposure IgE is produced and binds to
mast cells and basophils On reexposore multimeric antigen cross links two IgE receptors initiating a signal transduction cascade Which culminates in increase of calcium and release of mediators such as histamine,proteases,proteoglycans,and P.A.F.
TRYPTASE
Neutral serine proteinase
ETIOLOGY
NMBAs 69.2%
succinyl choline ,rocuronium,atra. NRL12.1% latex gloves Antibiotics-8% penicillin,and beta lactams Colloid- 3.7% dextran,gelatin Hypnotics-2.7% propofol,thiopentone Opioids- 1.4% morphine ,meperidine Local anesthetic agentMiscellaneous -aprotinin,chymopapain,protamine,
TREATMENT
DISCONTINUATIN OF DRUG OR ANESTHETIC
oxygen delivery and maintain airway IV FLUIDS (2-4litres) for compensation of systemic vasodilation. EPINEPHRINE is drug of choice because its alpha 1 effects support the blood pressure and beta 2 effects provide bronchial smooth muscle relaxation 5-10micrograms initial bolus upto 100-500mic. For vascular collapse , start drip with 1 mic./min. for refractory hypotension
CONTINUED.
H1 blockers diphenhydramine 25-50 mg should be
used early but their role is controversial once cardiac sym. Set in H2 blockers ranitidine 150 ms bolus or cim etdine 400mg bolus should be added Bronchodilators eg.albuterol and ipratropium bromide nebulizers Corticosteroids decrease airway swelling and prevent recurrence of sym.as seen in protracted and biphasic ana.hydrocortisone is preferred steroid because of fast onset
CONTINUED..
Extubation should be delayed .because airway
swelling and inflamation may continue for 24 hours . Patient should be managed in I.C.U.
PREVENTION
MUSCLE RELAXANTS
NMBAs are most common cause of anaphylaxis
succinylcholine because it contains a flexible molecule that crossreacts link 2 mast cell IgE receptors and induce mast cell degranulation N.M.B. Induce 2 type of reactions - IgE dependent => NH4+ main antigenic epitope - direct mast cell activation => benzylisoquinolinium cisatracurium has lowest risk of mast cell activation
Cross reactivity depend on configuration, flexibility,inter-ammonium distant Unusual to allergic to all NMBAs But keep in mind some pt. might suffer from multiple allergies
PREVENTION
Avoid NMBAs for patient with previous
LOCAL ANASTHETICS
vasovagal responses ,tachycardia,lighthededness or
Metallic taste , perioral numbness can result from intravascular injection of local anesthetic or epinephrine Anaphylaxis is very rare, type 4 reaction is most common Amide-rare , ester< 1% for anaphylaxis Ester metabolite=> PABA usually cause type I reaction Preservative => methylparaben
HYPNOTICS
Cross reactivity between thiopental sodium
barbitone,methohexital( rare anaphylaxis) Propofol => alkyl phenol that bear 2 isopropyl groups that act as antigenic epitopes - cross react with eggs ,soy and lechitins in propofol vehicle ? upto now no evidence support this postulate
OPOIDS
generalized reaction to opioids usually result
from nonspecific mast cell activation Skin mast cell are sensitive to nonspecific activation , in contrast to heart,GI,lung How about basophil? Classification of opioid - phenanthrene (morphine,codeine) - phenylpiperedine(phentanyl,meperidine) - diphenylheptane(methadone,propoxyphene
Fentanyl appear not to activate mast cell Data in cross reactivity of opioid subclass is inconclusive SPT for opioids is not useful Placebo controlled challenges may be required to diagnose opioid allergy
NATURAL RUBBER
Divided into 2 groups
- atopic
- significant exposure=>HCP, Neural tube defect
% of perioperative anaphylaxis
OTHER AGENTS
Hyaluronidase
Oxytocin
dyes Aprotinin
PROTAMINE
Isolate from the sperm of fish
cardiac catheterization
conclusion
Prevance of peri-operative anaphylaxis
Diagnostic approach
NMBAs is MCM cause Diagnostic test