Dr. Az Rifki, SpAn.

KIC
Dept. Anestesiologi dan Reanimasi
FK-FKG Univ. Baiturrahmah / RS Islam Siti Rahmah
Padang
Objectives
 Definitions

 Types of allergic reactions Anaphylaxis

 Signs and Symptoms of Anaphylaxis

 Appropriate treatments
Introduction

 Anaphylaxis is a rare, but potentially

reversible, cause of cardiac arrest
 Anaphylaxis is a severe life-threatening,
generalised or systemic hypersensitivity
reaction
 Investigations will show whether the reaction
is allergic (immunoglobulin E (IgE) or non IgE
mediated) or non-allergic anaphylaxis
Introduction (cont,)

 An anaphylactic reaction is generally defined

as a severe, systemic allergic reaction
characterized by multisystem involvement,
including the airway, vascular system,
gastrointestinal tract and skin.
 Severe cases may cause complete airway
obstruction secondary to laryngeal oedema,
bronchospasm, hypotension, cardiovascular
collapse and death.
Introduction (cont,)

 Other symptoms include rhinitis,

conjunctivitis, abdominal pain, vomiting,
diarrhoea and a sense of impending doom.
 There is also usually a colour change; the
patient may appear either flushed or pale.
 Anaphylactic reactions vary in severity, and
progress may be rapid, slow or (unusually)
biphasic. Rarely, manifestations may be
delayed (this may occur with latex allergy),
or persist for more than 24 h.
Definitions

 ANAPHYLAXIS
• Clinical syndrome with multi-organ symptoms
 cutaneous
 respiratory
 cardiovascular
 gastrointestinal
 IgE-mediated mechanism
 ANAPHYLACTOID
 Identical symptoms as anaphylaxis
 Non-IgE-mediated mechanism
 Definition of Anaphylaxis
 Anaphylaxis is likely when any 1 of the 3
criteria are fulfilled
 (1) Acute onset of an illness (minutes to hours) with
involvement of
 Skin/mucosal tissue (eg, hives, generalizeditch/flush,
swollen lips/tongue/uvula)
AND
 Airway compromise (eg, dyspnea, wheeze / bronchospasm,
stridor, reduced PEF)
OR
 Reduced BP or associated symptoms (eg, collapse, syncope)

Sampson HA et al. J Allergy Clin Immunol 2006;117:391-7

 Definition of Anaphylaxis cont’d

 (2) Two or more of the following after exposure to a

likely allergen for that patient (minutes to hours)
 Skin/mucosal tissue (eg, hives, generalized itch/flush,
swollen lips/tongue/uvula)
 Respiratory compromise (eg, dyspnea,
wheeze/bronchospasm, stridor, reduced PEF)
 Reduced BP or associated symptoms (eg, hypotonia,
syncope)
 Persistent gastrointestinal symptoms (eg, crampy
abdominal pain, vomiting)

Sampson HA et al. J Allergy Clin Immunol 2006;117:391-7.

Definition of Anaphylaxis
cont’d
 (3) Hypotension after exposure to known
allergen for that patient (minutes to hours)
 Infants and children: low systolic BP
(agespecific) or >30% drop in systolic BP
 Adults: systolic BP <90 mm Hg or >30% drop
from their baseline

Sampson HA et al. J Allergy Clin Immunol 2006;117:391-7.

Anaphylaxis

 Is a severe allergic reaction

 Involves more than one bodily system,
for example the skin and respiratory
tract or gastrointestinal tract
 Can be life-threatening
 Epinephrine, or adrenaline, is the
medication of choice for handling an
anaphylactic reaction
 Anaphylaxis

Incidence

 21 per 100,000 person-years (95% confidence

interval [CI]: 17 - 25 per 100,000 person-years)1

 10.5 per 100,000 person-years among children

(95% CI: 8.1 – 13.3 per 100,000 person-years)2

1
Yocum et al. J Allergy Clin Immunol 1999
2
Bohlke et al. J Allergy Clin Immunol 2004
Estimated prevalence of
Generalized Allergic Reaction*
Insect sting 3% of adults
Food 1-3% of children
Drug 1% of adults
RCM 0.1% of cases
Allergen immuno Tx 3% of patients
Latex 1% of adults
All causes 5% of adults

*urticaria / angioedema or dyspnea or hypotension

Anaphylaxis Mediators

Histamine
 H1: smooth muscle contraction  vasc permeability
 H2:  vascular permeability
 H1+H2: vasodilatation, pruritus
 Leukotrienes
 Smooth muscle contraction
  vascular permeability and dilatation
 Nitric Oxide
 Smooth muscle relaxation
  vascular permeability and dilatation

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 Anaphylaxis -Temporal Pattern

 Uniphasic

Biphasic
 Initial allergic reaction
 Recurrence of same manifestations up to 8 hours
later

Protracted
 Up to 32 hours
 May not be prevented by glucocorticoids

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Causes of IgE-Mediated Anaphylaxis

 Antibiotics and other medications

-lactams, tetracyclines, sulfas
 Intra-operative anaphylaxis may be caused by
antibiotics, parenteral anesthetic agents (especially
the muscle relaxants), and latex.
 Foreign proteins
Latex, hymenoptera venoms, heterologous sera, protamine, seminal
plasma, chymopapain
 Foods
Shellfish, peanuts, and tree nuts
 Exercise induced
5,644 cases of anaphylaxis during anesthesia
over last 25 years (1980-2004)

 Muscle relaxants 3,509 (62%)

 Latex 955 (17%)
 Antibiotics 365 (6.4%)
 Hypnotics 349 (6.1%)
 Colloids 194 (3.4%)
 Opioids 112 (1.9%)
 Others 160 (2.8%)
 Treatment (continued)

 Corticosteroids
 1-2 mg/kg prednisone PO (max 75 mg)
 2 mg/kg methylpredisolone IV (max 250 mg)
 Not effective in protracted anaphylaxis
 Effective in iodinated dye prophylaxis
 Inhaled beta-agonists
Albuterol 2.5 mg q 15-20 min

 Glucagon (consider if patient is on -blocker)