Anaphylaxis

Ethylene oxide sterilization of medical devices: a review

Structure, enzymatic activities, glycation and therapeutic potential of human serum albumin: A natural cargo

Background: Anaphylactic reactions (ARs) in high-risk pediatric patients undergoing general anesthesia, especially those with spina bifida, have been attributed to anesthetics, muscle relaxants, antimicrobials, ethylene oxide, and latex. Methods: To identify risk factors for AR during general anesthesia and to investigate the role of latex allergy, we studied epidemiologic and immunologic characteristics of patients with ARs during general anesthesia during a 13-month cluster of such reactions at Children's Hospital of Wisconsin (case patients). Patients with AR were compared with patients with spina bifida undergoing uneventful general anesthesia during the same period (control patients). For each case patient and control patient, we conducted a chart review; a parental interview; skin prick testing with latex, anesthetics, aeroallergens, and banana extract; ELISA and RAST for latex-specific IgE; a total serum IgE; and an ELISA for IgE antibody to ethylene oxide. Results: Anaphylactic reactions occurred exclusively in patients with spina bifida ( n = 10) or patients with a congenital urinary tract anomaly ( n = 1). Case-patients were more likely than control patients to have a history of asthma ( p = 0.002), rubber contact allergy ( p = 0.001), food allergy ( p = 0.001), rash caused by adhesive tape ( p = 0.05), daily rectal disimpaction ( p p p = 0.027), or elevated total serum IgE levels ( p = 0.002). Multivariate analysis identified non-white race, rubber contact allergy, history of food allergy, and nine or more surgical procedures as significant independent risk factors. Logistic model equation identified the predicted probability of AR with a sensitivity, specificity, and positive predictive value of 82%, 97%, and 82%, respectively. Conclusions: These findings demonstrate that atopy, especially symptomatic latex allergy, is associated with AR during anesthesia in patients with spina bifida. Until a standardized latex test is available, a medical history of immediate rubber contact allergy, non-white race, food allergy, or nine or more prior surgical procedures can identify patients with spina bifida at highest risk for ARs. A complete history, including rubber contact and food allergy, should be compiled on all patients with spina bifida before surgery. (J ALLERGY CLIN IMMUNOL 1994;94:53-61.).

https://www.jacionline.org/article/0091-6749(94)90071-X/pdf

A cluster of anaphylactic reactions in children with spina bifida during general anesthesia: Epidemiologic features, risk factors, and latex hypersensitivity

Ethylene oxide (ETO), an alkylating compound of high chemical reactivity, is widely used for gas sterilization, but recently serious ETO side reactions have been recognized. With chronic ETO exposure, increased spontaneous abortion, sister chromatid exchange, and leukemia are observed. After medical use of ETO outside nephrology, contact dermatitis, cardiopulmonary shock (during cardiopulmonary surgery), allergic local reactions to ETO sterilized lenses, and anaphylactoid reactions to ETO sterilized catheters have been described. In numerous dialysis patients widespread hypersensitivity to ETO has been documented by skin prick test and ETO radioallergosorbent test (RAST). Furthermore an anaphylactoid "first-use reaction" was described in dialyzed patients, most of whom were using hollow-fiber dialyzers. After long discussions whether complement activation versus hypersensitivity is the cause of such acute anaphylactoid reactions, more recent studies using either ETO RAST or basophil degranulation tests implicate ETO hypersensitivity as their major cause. The high prevalence of sensitization to ETO and the frequency, unpredictability, and potential danger of anaphylactoid reactions to ETO lead to the conclusion that ETO sterilization of dialyzers should be discontinued, since alternative modalities of sterilization are currently available.

Ethylene Oxide (ETO) as a Major Cause of Anaphylactoid Reactions in Dialysis (A review)

We have measured total antibody and IgE directed against ethylene oxide-altered human serum albumin (ETO-HSA) in the sera of 24 patients who have experienced anaphylaxis during hemodialysis and of 41 patients who have not had such episodes during hemodialysis. ETO is used to sterilize dialyzers and other medical equipment. The geometric mean level of IgE to ETO-HSA in patients with reactions (0.9 ng ETO-HSA bound to IgE per milliliter of serum) is significantly higher than in nonreacting patients (0.1 ng/ml, p p p p

https://www.jacionline.org/article/0091-6749(85)90736-5/pdf

IgE against ethylene oxide-altered human serum albumin in patients with anaphylactic reactions to dialysis☆

Anaphylactic reactions to dialysis have been associated with antibody to human serum albumin (HSA) that has been reacted with ethylene oxide (ETO). ETO, an agent used to sterilize dialyzers, is a potent alkylator of proteins. We have studied the antigenic characteristics of ETO-HSA. By use of immunoelectrophoresis we have demonstrated differences in electrophoretic mobility between HSA and ETO-HSA. By gel chromatography we have observed an apparent increase in the molecular weight of ETO-HSA as compared to HSA. Antigenic activity of ETO-HSA as determined by the technique of Lidd and Farr is found in all molecular weight fractions. Cutaneous reactivity to ETO-HSA can be transferred to subhuman primates. That reactivity is lost if the sera are heated to 56 °C for 4 hours. Antibody activity to ETO-HSA cannot be inhibited by ETO-glycine or HSA but can partially be inhibited by ETO-polylysine or ETO-ovalbumin. This suggests that antibody is directed against a new antigenic determinant on the ETO-protein moiety, probably an ETO-amino acid determinant like lysine.

https://www.jacionline.org/article/0091-6749(85)90669-4/pdf

Characterization of an antigen in acute anaphylactic dialysis reactions: ethylene oxide-altered human serum albumin.

Many immunologic and nonimmunologic mechanisms are responsible for producing occupational lung disease Host factors such as atopic status, smoking history, and hyperreactivity of the lung all influence how a worker will respond to toxic and antigenic substances in the workplace Particle factors such as size, shape, and solubility influence the site of lung disease that develops Asthma in the workplace can be mediated by a variety of immunologic and nonimmunologic mechanisms An interaction of immunologic and nonimmunologic processes is the most likely pathogenesis for HP The role of immunologic processes in the pathogenesis of occupational pneumoconioses is unknown

Pathogenesis of occupational lung disease.

We retrospectively reviewed charts of asthmatics who have coexistent cardiac disease. Twenty-nine patients with a mean age of 64.6 received 621 injections of epinephrine for acute asthma. Clinical improvement in asthma was noted and only three patients experienced a total of five (0.8%) adverse reactions temporally related to the administration of epinephrine. Twelve asthmatic patients were treated with beta adrenergic receptor blockers for a coexistent cardiac disease. In general, these patients tolerated the beta-blocker without a significant deterioration in respiratory function. Epinephrine and beta-blockers may be used safely in some asthmatics with heart disease when the medication is indicated and cautiously administered.

Bruce F. Paterson

Papers

IgE against ethylene oxide-altered human serum albumin in patients with anaphylactic reactions to dialysis☆

Characterization of an antigen in acute anaphylactic dialysis reactions: ethylene oxide-altered human serum albumin.

Pathogenesis of occupational lung disease.

The management of coexisting asthma and cardiac disease.

181 Antibody against ethylene oxide — Human serum albumin in patients with anaphylactic reactions to dialysis