1. The pathophysiology of anaphylaxis

Stridor

• Stridor

• Hoarseness

• Angioedema

• Sneezing

Wheezing

• Wheezing

• Dyspnea

Generally occurs immediately after drug injection (2-15 mins).

• Generally occurs immediately after drug injection (2-15 mins).

• Generally related to iv agents.

• Rarely occurs 2.5 hour after the drug therapy.

• No death reports > 6 hours after the reaction.

• Reaction time following oral drug intake is unpredictable ?

STOP the responsible agent

• STOP the responsible agent

• Call for HELP

• Warn the SURGEON

• Trandelenburg position

• Ventilation+%100 O2

• Fluid therapy:

• 500-1000 mL iv adult, ≥20 mL/kg çocuk
• (%09 NaCl, RL)

ADULT:

• ADULT:

• Severe anaphylaxis

• 0.1-1 mg iv
• 0.5-0.8 mg im

• Mild rxn: 10-50 micg iv

CORTICOSTEROID

• CORTICOSTEROID

• Adult

• HIDROCORTISON 250 mg,
• M.Prednisolon 80 mg iv

• Pediatric

• HIDROCORTISON 50-100 mg,
• M.Prednisolon 2 mg/kg iv

• NORADRENALIN: 0.05-0.1 mcg/kg/min

• VASOPRESSIN : 2-10 IU iv doses until response.

• GLUCAGON : 1-2 mg iv doses until response (in patients taking beta-blocker & unresponsive to high dose adrenaline).

Polen, animal fur, dust atopy

• Polen, animal fur, dust atopy

• Former prolonged latex exposure

• may develop reaction with LATEX.

Anaphylaxis with Local Anesthetics is RARE; prefer Regional or local anesthesia.

• Anaphylaxis with Local Anesthetics is RARE; prefer Regional or local anesthesia.

• Agent of choice for General anesthesia is VOLATILE. “No Anaphylaxis is reported”

• AVOID Latex & Neuromusculer blockers !

• Antihistaminic/steroid premedication does not prevent “anaphylactic shock” ?

• If known to cause a previous reaction, avoid using that drug/agent.

After a moderate-severe anaphylactic rxn:

• After a moderate-severe anaphylactic rxn:

• Follow-up with blood (triptase), then skin test.
• Skin test: skin prick, intradermal test (IgE) or
• If there is a local or disseminated urticeria related to Chlorhexidin skin test is necessary.

• Follow-up is not necessary:

• Erhythema around the injection site, isolated bronchospasm in patients with previous bronchial reactivity.

Symptoms

• Symptoms

• Severity of the reaction

• Onset time and length of the reaction,

• Therapy

• All the agents used before the reaction

• Anesthesia form, notes

• Fill the advers event form.

Serum triptase & IgE Ab.

• Serum triptase & IgE Ab.

• Blood sample for analysis must be drawn within 1-4 hrs following the rxn. 5-10 mL blood, serum. The timing of the blood sampling after the reaction should be noted ?

• Control blood sample should be drawn before Anaphylaxis or 24 hrs after the reaction.

• Blood for IgE analysis can be sampled within 6 months after the reaction.

Skin test:

• Skin test:

• Evaluates mast cell rxn by IgE. Salin (-) control, Histamin (+) control. Test has to be done 6 weeks after the reaction.
• Bir NMBA ile (+) sonuç alındıysa, diğer NMB test edilmeli.
• Bir LA rxn varsa diğerleri test edilmeli. Cross reactivity.

• Drug provacation test: RISKY !

• It has to be performed after the skin test.

• Generally 1/10 of the therapeutic dose of the drug responsible for the reaction is given via same route.

NMBA. (skin prick test “gold standart”)

• NMBA. (skin prick test “gold standart”)

• 1/5.000-10.000 (france,norway,GB).
• Other countries 1/50.000-1/150.000.

• Latex (<5-17.7%)

• Antibiotics. (Penicillin 0.1%)

• 15% of all the Anaphylactic rxns

• Chlorhexidin.

• 12% of all the rxns during anesthesia are related to it (in denmark).

• Gelatin (4%-france). HES (0.006%)

• Ketamine, Midazolam. Very rare.

• Opioids. Low incidance.

• L.Anesthetics. Very low.

• Propofol. (2.3%) Rare.

• Thiopental. 1/23.000-29.000

• (higher in female)

• NSAID. (general population 1%) rarely a problem during anesthesia. COX-2 inhibitors may be safer ?

Bracelet

• Bracelet

• Detailed epicrisis