Identification of risk factors of severe hypersensitivity reactions in general anaesthesia

Clinical and Molecular Allergy

Elide A Pastorello²  Michele Nichelatti⁴  Chrysi Stafylaraki¹  Maria G Aversano¹  Laura M Losappio¹  Jan Schroeder¹  Joseph Scibilia¹  Luca G Balossi¹  Laura Farioli³  Gianluigi Micarelli¹  Ambra Mascheri¹  Donatella Preziosi¹  Corrado Mirone¹ 

[1] Allergology and Immunology Unit, Niguarda Ca’ Granda Hospital, Milan, Italy;Allergology and Immunology Unit, Niguarda Ca’ Granda Hospital and Department of Clinical Science and Community Health Università degli Studi of Milan, Milan 20162, Italy;Department of Laboratory Medicine Niguarda Ca’ Granda Hospital, Milan, Italy;Service of Biostatistics, Niguarda Ca’ Granda Hospital, Milan, Italy

关键词: Angiotensin-converting enzyme inhibitor;    Hypertension;    Age;    Serum tryptase;    Neuromuscular blocking agents;    Severity;    Anaphylaxis;    Risk factors;    Hypersensitivity;    General anaesthesia;   

Others  :  1219067
DOI  :  10.1186/s12948-015-0017-9

 received in 2015-01-16, accepted in 2015-04-01,  发布年份 2015

【 摘 要 】

Background

Hypersensitivity reactions to anaesthetic agents are rare but often severe, with a mortality ranging from 4 to 9% in IgE-mediated events. Identification of the risk factors may contribute to limit the incidence of these reactions. The aim of our study was to search for possible risk factors of severe perioperative hypersensitivity reactions in our study population.

Methods

For this study we retrospectively reviewed data from 193 patients who experienced drug hypersensitivity reactions during general anaesthesia. The diagnostic protocol consisted of 1) history of the reaction, 2) measurement of serum baseline tryptase and specific IgE-assays for latex, beta-lactams and succinylcholine, 3) skin tests for the agents listed in the anaesthesia chart and for others likely to be safe for future use, latex, and others medications administered during the perioperative period (i.e. antibiotics), 4) subdivision of our patients on the basis of two criteria: a) grade of severity of clinical reactions according to the Ring and Messmer classification; b) results of skin tests and/or serum specific IgE-assays.

Results

One hundred of 193 patients had reactions of grade I, 32/193 patients had reactions of grade II, 55/193 patients had reactions of grade III and 6/193 patients had reactions of grade IV. A diagnosis of IgE-mediated reaction was established in 55 cases (28.50%); the most common causes were neuromuscular blocking agents, followed by latex and beta-lactams. Severe reactions were associated with older age (p = 0.025), asthma (p = 0.042), history of hypertension (p = 0.001), intake of serum angiotensin converting enzyme inhibitor medication (p = 0.012) or serum angiotensin II antagonist (p = 0.033), higher levels of basal tryptase (p = 0.0211). Cardiovascular symptoms (p = 0.006) and history of hypersensitivity to antibiotics (p = 0.029) were more frequently reported in IgE-mediated reactions.

Conclusions

We confirmed the relevance of several clinical features as risk factors for anaphylactic reactions induced by anaesthetic agents: older age, asthma, hypertension and antihypertensive drugs. We observed increased levels of serum basal tryptase in severe reactions: this finding may signify that this biomarker is useful for the identification of patients at risk.

【 授权许可】

   
2015 Mirone et al.; licensee BioMed Central.

【 图 表 】

Figure 1.

【 参考文献 】

• [1]Liew WK, Williamson E, Tang ML. Anaphylaxis fatalities and admissions in Australia. J Allergy Clin Immunol. 2009; 123(2):434-42.
• [2]Pumphrey R. Anaphylaxis: can we tell who is at risk of a fatal reaction? Curr Opin Allergy Clin Immunol. 2004; 4(4):285-90.
• [3]Jerschow E, Lin RY, Scaperotti MM, McGinn AP. Fatal anaphylaxis in the United States, 1999–2010: Temporal patterns and demographic associations. J Allergy Clin Immunol. 2014; 134(6):1318-1328.
• [4]Mertes PM, Malinovsky JM, Jouffroy L. Working Group of the SFAR and SFA, Aberer W, Terreehorst I, Brockow K, Demoly P; ENDA; EAACI Interest Group on Drug Allergy. Reducing the risk of anaphylaxis during anesthesia: 2011 updated guidelines for clinical practice. J Investig Allergol Clin Immunol. 2011; 21(6):442-53.
• [5]Mertes PM, Alla F, Tréchot P, Auroy Y, Jougla E. Groupe d’Etudes des Réactions Anaphylactoïdes Peranesthésiques. Anaphylaxis during anesthesia in France: an 8-year national survey. J Allergy Clin Immunol. 2011; 128(2):366-73.
• [6]Johansson SG, Hourihane JO, Bousquet J, Bruijnzeel-Koomen C, Dreborg S, Haahtela T et al.. EAACI (the European Academy of Allergology and Cinical Immunology) nomenclature task force. A revised nomenclature for allergy. An EAACI position statement from the EAACI nomenclature task force. Allergy. 2001 Sep;56 (9):813–24. Review. Erratum in. Allergy. 2001; 56(12):1229.
• [7]Ruëff F, Przybilla B, Biló MB, Müller U, Scheipl F, Aberer W et al.. Predictors of severe systemic anaphylactic reactions in patients with Hymenoptera venom allergy: importance of baseline serum tryptase-a study of the European Academy of Allergology and Clinical Immunology Interest Group on Insect Venom Hypersensitivity. J Allergy Clin Immunol. 2009; 124(5):1047-54.
• [8]Bonadonna P, Perbellini O, Passalacqua G, Caruso B, Colarossi S, Dal Fior D et al.. Clonal mast cell disorders in patients with systemic reactions to Hymenoptera stings and increased serum tryptase levels. J Allergy Clin Immunol. 2009; 123(3):680-6.
• [9]Summers CW, Pumphrey RS, Woods CN, McDowell G, Pemberton PW, Arkwright PD. Factors predicting anaphylaxis to peanuts and tree nuts in patients referred to a specialist center. J Allergy Clin Immunol. 2008; 121(3):632-638.
• [10]Bock SA, Muñoz-Furlong A, Sampson HA. Fatalities due to anaphylactic reactions to foods. J Allergy Clin Immunol. 2001; 107(1):191-3.
• [11]Hourihane JO’B, Kilburn SA, Nordlee JA, Hefle SL, Taylor SL, Warner JO. An evaluation of the sensitivity of subjects with peanut allergy to very low doses of peanut protein: a randomized, double-blind, placebo-controlled food challenge study. J Allergy Clin Immunol. 1997; 100(5):596-600.
• [12]Greenberger PA, Rotskoff BD, Lifschultz B. Fatal anaphylaxis: postmortem findings and associated comorbid diseases. Ann Allergy Asthma Immunol. 2007; 98(3):252-7.
• [13]Mueller UR. Cardiovascular disease and anaphylaxis. Curr Opin Allergy Clin Immunol. 2007; 7(4):337-41.
• [14]González De Olano D, De la Hoz Caballer B, Núñez López R, Sánchez Muñoz L, Cuevas Agustín M, Diéguez MC et al.. Prevalence of allergy and anaphylactic symptoms in 210 adult and pediatric patients with mastocytosis in Spain: a study of the Spanish network on mastocytosis (REMA). Clin Exp Allergy. 2007; 37(10):1547-55.
• [15]Brockow K, Jofer C, Behrendt H, Ring J. Anaphylaxis in patients with mastocytosis: a study on history, clinical features and risk factors in 120 patients. Allergy. 2008; 63(2):226-32.
• [16]Müller UR. Elevated baseline serum tryptase, mastocytosis and anaphylaxis. Clin Exp Allergy. 2009; 39(5):620-2.
• [17]Simons FE, Ardusso LR, Bilò MB, Cardona V, Ebisawa M, El-Gamal YM et al.. International consensus on (ICON) anaphylaxis. World Allergy Organ J. 2014; 7(1):9. BioMed Central Full Text
• [18]Ewan PW, Dugué P, Mirakian R, Dixon TA, Harper JN, Nasser SM. BSACI. BSACI guidelines for the investigation of suspected anaphylaxis during general anaesthesia. Clin Exp Allergy. 2010; 40(1):15-31.
• [19]Torres MJ, Blanca M, Fernandez J, Romano A, Weck A, Aberer W et al.. ENDA; EAACI Interest Group on Drug Hypersensitivity. Diagnosis of immediate allergic reactions to beta-lactam antibiotics. Allergy. 2003; 58(10):961-72.
• [20]Johansson SG, Bieber T, Dahl R, Friedmann PS, Lanier BQ, Lockey RF et al.. Revised nomenclature for allergy for global use: Report of the Nomenclature Review Committee of the World Allergy Organization, October 2003. J Allergy Clin Immunol. 2004; 113(5):832-6.
• [21]Ring J, Laubenthal H, Messmer K. Incidence and classification of adverse reactions to plasma substitutes. Klin Wochenschr. 1982; 60(17):997-1002.
• [22]Poulos LM, Waters AM, Correll PK, Loblay RH, Marks GB. Trends in hospitalizations for anaphylaxis, angioedema, and urticaria in Australia, 1993–1994 to 2004–2005. J Allergy Clin Immunol. 2007; 120(4):878-84.
• [23]Ma L, Danoff TM, Borish L. Case fatality and population mortality associated with anaphylaxis in the United States. J Allergy Clin Immunol. 2014; 133(4):1075-83.
• [24]Clark S, Wei W, Rudders SA, Camargo CA. Risk factors for severe anaphylaxis in patients receiving anaphylaxis treatment in US emergency departments and hospitals. J Allergy Clin Immunol. 2014; 134(5):1125-30.
• [25]Renaudin JM, Beaudouin E, Ponvert C, Demoly P, Moneret-Vautrin DA. Severe drug-induced anaphylaxis: analysis of 333 cases recorded by the Allergy Vigilance Network from 2002 to 2010. Allergy. 2013; 68(7):929-37.
• [26]Deliargyris EN, Upadhya B, Sane DC, Dehmer GJ, Pye J, Smith SC et al.. Mast cell tryptase: a new biomarker in patients with stable coronary artery disease. Atherosclerosis. 2005; 178(2):381-6.
• [27]Kounis NG, Tsigkas G, Almpanis G, Kounis GN, Mazarakis A, Hahalis G. Tryptase levels in coronary syndromes and in hypersensitivity episodes: a common pathway towards Kounis syndrome. Atherosclerosis. 2011; 219(1):28-9.
• [28]Kucharewicz I, Bodzenta-Lukaszyk A, Szymanski W, Mroczko B, Szmitkowski M. Basal serum tryptase level correlates with severity of hymenoptera sting and age. J Investig Allergol Clin Immunol. 2007; 17(2):65-9.
• [29]Guenova E, Volz T, Eichner M, Hoetzenecker W, Caroli U, Griesinger G et al.. Basal serum tryptase as risk assessment for severe Hymenoptera sting reactions in elderly. Allergy. 2010; 65(7):919-23.
• [30]Mertes PM, Laxenaire MC, Alla F. Groupe d’Etudes des Réactions Anaphylactoïdes Peranesthésiques. Anaphylactic and anaphylactoid reactions occurring during anesthesia in France in 1999–2000. Anesthesiology. 2003; 99(3):536-45.