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Anaesthesiology
The Allergic Response
Built from Barash Clinical Anesthesia, 9th Edition
What’s inside
9 sections · 152 slides
Overview
- Scope of this topic
- Perioperative exposure to foreign substances
- Purpose of the immune system
- Defining features of an immunologic mechanism
Basic immunologic principles
- Cell-mediated and humoral immunity
- Cytokines and chemokines in the inflammatory response
- Antigens and haptens
- Formation of the hapten-macromolecule complex
- Agents administered during anaesthesia that act as antigens
- T lymphocytes
- Cytotoxic T cells and natural killer cells
- B lymphocytes and plasma cells
- Antibody structure and function
- Consequences of antigen-antibody binding
- Therapeutic agents based on Fab fragments
- Five classes of human immunoglobulin
- Biologic characteristics of immunoglobulins
- Effector cells of the immune response
- Monocytes and macrophages
- Neutrophils and eosinophils
- Basophils and mast cells
- Cytokines and interleukins
- Nomenclature and actions of the interleukins
- The complement system
- Classic and alternate pathways of complement activation
- C1 esterase inhibitor deficiency and angioedema
- Effects of anaesthesia on immune function
Hypersensitivity responses
- The Gell and Coombs classification
- Four types of hypersensitivity
- Type I immediate hypersensitivity
- Type II cytotoxic reactions
- Mechanisms and examples of type II cell damage
- Type III immune complex reactions
- Type IV delayed hypersensitivity reactions
- Clinical settings of type IV reactions
Intraoperative allergic reactions
- Incidence and outcome of perioperative anaphylaxis
- Timing and presentation under anaesthesia
- Origin of the term anaphylaxis
- Recognition of anaphylaxis during regional and general anaesthesia
- IgE-mediated pathophysiology of anaphylaxis
- Three organ systems affected in anaphylaxis
- Sequence of events in intraoperative anaphylaxis
- Histamine receptors and their effects
- The wheal and flare response
- Peptide mediators of anaphylaxis
- Arachidonic acid metabolites
- Prostaglandins in anaphylaxis
- Kinins and platelet-activating factor
- Recognition of anaphylaxis
Non-IgE-mediated reactions
- Non-IgE mechanisms producing the same syndrome
- Anaphylatoxins C3a and C5a
- Biologic effects of anaphylatoxins
- Granulocyte aggregation and pulmonary leukostasis
- Clinical syndromes linked to complement and neutrophil aggregation
- Hereditary angioedema
- Treatment of hereditary angioedema
- Non-immunologic histamine release
- Vancomycin-induced histamine release
- Drugs capable of non-immunologic histamine release
- Structural determinants of histamine release
- Mast cell ultrastructure after neuropeptide stimulation
- Mechanisms of mediator release from cutaneous mast cells
- Antihistamine pretreatment
Treatment plan
- Principles of the treatment plan
- Initial therapy for anaphylaxis
- Duration of severe reactions and monitoring
- Airway maintenance and oxygenation
- Discontinuing anaesthetic drugs
- Volume expansion in anaphylactic shock
- Echocardiography and pulmonary oedema
- Actions of epinephrine in anaphylaxis
- Epinephrine dosing and route
- Cautions with epinephrine administration
- Antihistamines in secondary treatment
- Catecholamine infusions
- Bronchodilators
- Corticosteroids
- Airway evaluation before extubation
- Management of refractory hypotension
- Management of anaphylaxis during general anaesthesia
- Corticosteroid choice by suspected mechanism
The patient with allergies
- Frequency of allergic drug reactions
- Misuse of the label allergy
- Predictable adverse drug reactions
- Morphine as an example of a predictable reaction
- Drug interactions as predictable reactions
- Unpredictable adverse drug reactions
- Predictable versus unpredictable reactions
- Clinical clues that a reaction is allergic
- Timing as the key diagnostic information
- Immunologic mechanisms of drug allergy
- The four faces of penicillin allergy
- Agents implicated during anaesthesia
- Agents implicated in allergic reactions during anaesthesia
- Value of a history of allergy or atopy
- Evaluating a patient after a suspected reaction
- Limitations of challenge testing
- Indications for allergy testing after a reaction
- Leukocyte histamine release testing
- In vitro immunologic testing
- Intradermal skin testing
Agents implicated in allergic reactions
- Agents most often implicated perioperatively
- French national survey of perioperative anaphylaxis
- Geographic variation in reported causes
- United States skin test database findings
- Causative agents in the United States series
- Danish findings and chlorhexidine
- Antibiotic allergy in surgical patients
- Vancomycin as a histamine releaser
- Cross-reactivity between penicillins and cephalosporins
- Value of penicillin skin testing
- Practical management of the penicillin allergy label
- Uncertainty about other beta-lactams
- Latex allergy
- Groups at increased risk of latex anaphylaxis
- Latex sensitisation among anaesthesiologists
- Prevention and management of latex allergy
- Precautions for the latex-allergic patient
- Reactions to local anaesthetics
- Testing for local anaesthetic allergy
- Reverse placebo provocation
- Predictive value of local anaesthetic skin testing
- Molecular features making NMBAs antigenic
- Sex distribution and cross-reactivity of NMBA allergy
- Why NMBA anaphylaxis rates differ between countries
- False-positive skin responses to relaxants
- Prick testing thresholds for rocuronium and vecuronium
- Standardising NMBA skin testing
Summary and key points
- Summary of the allergic response
- Key points on mechanism
- Key points on recognition and treatment
- Key points on implicated agents
- References
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- Barash, Cullen, and Stoelting's Clinical Anesthesia, 9th Edition