1. The pathophysiology of anaphylaxis



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1. The pathophysiology of anaphylaxis

  • 1. The pathophysiology of anaphylaxis

  • 2. Clinical signs of anaphylaxis

  • 3. Differential diagnosis of anaphylaxis

  • 4. Spesific pharmacological and supportive treatment of anaphylaxis

  •  



A severe life threatening (Type I) immediate hypersensitivity reaction.

  • A severe life threatening (Type I) immediate hypersensitivity reaction.

  • The reaction occurs when the person reexposed to an ‘allergen’, which leads to IgE Ab during previous exposure.



    • Injected, inhaled or ingested substance
    • –usually drugs, food, insect venom- can serve as the allergen itself.




Allergen:

  • Allergen:

    • IgE + Ag Mast cells, basophils:
      • Histamin, triptase, leukotriens, eosinophilic chemotactic factors are released.
    • IgG leads to “complemant” system activation.


  • Non-Allergic (non-IgE, non-immun):

    • Reaction is developed by means of direct pharmacologic, toxic stimulus of the mast cells & basophils; Inflammatory mediators are released.








An identical or very similar clinical response (skin reaction) which is not mediated by IgE, or an Antigen-Antibody process.

  • An identical or very similar clinical response (skin reaction) which is not mediated by IgE, or an Antigen-Antibody process.



Anaphylaxis incidence during anesthesia is: 1/5.000-1/20.000

  • Anaphylaxis incidence during anesthesia is: 1/5.000-1/20.000

  • Multiple drug use duing general anesthesia may mask the symptoms.

  • Diagnosis during anesthesia is DIFFICULT !



Non-depolarizing neuromuscular blockers

  • Non-depolarizing neuromuscular blockers

  • Latex & antibiotics

  • Colloid solutions, barbituric acid

  • All drugs & agents used during surgery or anesthesia may be responsible

  • Mind the solutions or drugs used by the SURGEON !!



Topical, infiltration Local Anesthetic agents (<%1 anaphylaxis)

  • Topical, infiltration Local Anesthetic agents (<%1 anaphylaxis)

  • Irrigation solutions

  • Latex

  • Disinfectant

  • Markers (patent blue)







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



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:



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%)

  • 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



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