These parameters were developed by the Joint Task Force on Practice Parameters, representing the American Academy of Allergy, Asthma & Immunology (AAAAI); the American College of Allergy, Asthma & Immunology (ACAAI); and the Joint Council of Allergy, Asthma and Immunology. The AAAAI and the ACAAI have jointly accepted responsibility for establishing "The Diagnosis and Management of Anaphylaxis Practice Parameter: 2010 Update." This is a complete and comprehensive document at the current time. The medical environment is a changing environment, and not all recommendations will be appropriate for all patients. Because this document incorporated the efforts of many participants, no single individual, including those who served on the Joint Task Force, is authorized to provide an official AAAAI or ACAAI interpretation of these practice parameters. Any request for information about or an interpretation of these practice parameters by the AAAAI or ACAAI should be directed to the Executive Offices of the AAAAI, the ACAAI, or the Joint Council of Allergy, Asthma and Immunology. These parameters are not designed for use by pharmaceutical companies in drug promotion.

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The diagnosis and management of anaphylaxis practice parameter: 2010 update.

Between January 1, 1997 and December 31, 1998, 467 patients were referred to one of the allergo-anaesthesia centres of the French GERAP (Groupe d'Etudes des Reactions Anaphylactoides Peranesthesiques) network and were diagnosed as having anaphylaxis during anaesthesia. Diagnosis was established on the basis of clinical history, skin tests and/or a specific IgE assay. The most frequent cause of anaphylaxis was a neuromuscular blocking agent (69.2%). Latex was less frequently incriminated (12.1%) than in previous reports. A significant difference was observed between the incidence of anaphylactic reactions observed with each neuromuscular blocking agent and the number of patients who received each drug during anaesthesia in France throughout the study period (P<0.0001). Succinylcholine and rocuronium were most frequently incriminated. Clinical reactions to neuromuscular blocking drugs were more severe than to latex. The diagnostic value of specific IgE assays was confirmed. These results are consistent with changes in the epidemiology of anaphylaxis related to anaesthesia and are an incentive for the further development of allergo-anaesthesia clinical networks.

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Anaphylaxis during anaesthesia. Results of a two‐year survey in France

Summary
(1) The AAGBI has published guidance on management of anaphylaxis during anaesthesia in 1990, 1995 and 2003. This 2008 update was necessary to disseminate new information.
(2) Death or permanent disability from anaphylaxis in anaesthesia may be avoidable if the reaction is recognised early and managed optimally.
(3) Recognition of anaphylaxis during anaesthesia is usually delayed because key features such as hypotension and bronchospasm more commonly have a different cause.
(4) Initial management of anaphylaxis should follow the ABC approach. Adrenaline (epinephrine) is the most effective drug in anaphylaxis and should be given as early as possible.
(5) If anaphylaxis is suspected during anaesthesia, it is the anaesthetist’s responsibility to ensure the patient is referred for investigation.
(6) Serum mast cell tryptase levels may help the retrospective diagnosis of anaphylaxis: appropriate blood samples should be sent for analysis.
(7) Specialist (allergist) knowledge is needed to interpret investigations for anaesthetic anaphylaxis, including sensitivity and specificity of each test used. Specialist (anaesthetist) knowledge is needed to recognise possible non-allergic causes for the ‘reaction’. Optimal investigation of suspected reactions is therefore more likely with the collaboration of both specialties.
(8) Details of specialist centres for the investigation of suspected anaphylaxis during anaesthesia may be found on the AAGBI website http://www.aagbi.org.
(9) Cases of anaphylaxis occurring during anaesthesia should be reported to the Medicines Control Agency and the AAGBI National Anaesthetic Anaphylaxis Database. Reports are more valuable if the diagnosis is recorded following specialist investigation of the reaction.
(10) This guidance recommends that all Departments of Anaesthesia should identify a Consultant Anaesthetist who is Clinical Lead for anaesthetic anaphylaxis.

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Suspected Anaphylactic Reactions Associated with Anaesthesia

The present approach to the diagnosis, management and follow-up of anaphylaxis during anaesthesia varies in the Scandinavian countries. The main purpose of these Scandinavian Clinical Practice Guidelines is to increase the awareness about anaphylaxis during anaesthesia amongst anaesthesiologists. It is hoped that increased focus on the subject will lead to prompt diagnosis, rapid and correct treatment, and standardised management of patients with anaphylactic reactions during anaesthesia across Scandinavia. The recommendations are based on the best available evidence in the literature, which, owing to the rare and unforeseeable nature of anaphylaxis, mainly includes case series and expert opinion (grade of evidence IV and V). These guidelines include an overview of the epidemiology of anaphylactic reactions during anaesthesia. A treatment algorithm is suggested, with emphasis on the incremental titration of adrenaline (epinephrine) and fluid therapy as first-line treatment. Recommendations for primary and secondary follow-up are given, bearing in mind that there are variations in geography and resources in the different countries. A list of National Centres from which anaesthesiologists can seek advice concerning follow-up procedures is provided. In addition, an algorithm is included with advice on how to manage patients with previous suspected anaphylaxis during anaesthesia. Lastly, Appendix 2 provides an overview of the incidence, mechanisms and possibilities for follow-up for some common drug groups.

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Scandinavian Clinical Practice Guidelines on the diagnosis, management and follow-up of anaphylaxis during anaesthesia

Anaphylactic reactions to anaesthetic and associated agents used during the perioperative period have been reported with increasing frequency in most developed countries. Any drug administered in the perioperative period can potentially produce life-threatening immune-mediated anaphylaxis. Most published reports on the incidence of anaphylaxis come from France, Australia, the UK and New Zealand. These reflect an active policy of systematic clinical and/or laboratory investigation of suspected immune-mediated reactions. The estimated incidence of anaphylaxis ranges from 1:10,000 to 1:20,000. Muscle relaxants (69.1%) and latex (12.1%) were the most frequently involved drugs according to the most recent French epidemiological survey. Clinical symptoms do not afford an easy distinction between immune-mediated anaphylactic reactions and anaphylactoid reactions resulting from direct non-specific histamine release. Moreover, when restricted to a single clinical symptom, anaphylaxis can easily be misdiagnosed. Pre- and postoperative investigation must be performed to confirm the nature of the reaction, the responsibility of the suspected drugs and to provide precise recommendations for future anaesthetic procedures. These include plasma histamine, tryptase and specific IgE concentration determination at the time of the reaction and at skin tests 6 weeks later. In addition, since no specific treatment has been shown reliably to prevent the occurrence of anaphylaxis, allergy assessment must be performed in all high-risk patients. Treatment of anaphylaxis is aimed at interrupting contact with the responsible antigen, inhibiting mediator production and release, and modulating the effects of released mediators. It must be initiated as quickly as possible and relies on widely accepted principles. Finally, the need for proper epidemiological studies and the relative complexity of allergy investigation should be underscored. They represent an incentive for further development of allergo-anaesthesiology clinical networks to provide expert advice for anaesthetists and allergologists.

Allergic reactions occurring during anaesthesia

One hundred severe peranesthetic accidents occuring in hospitals in the eastern part of France were tested between 1975 and 1980 at the Immunological Unit of the University Hospital in Nancy Tests were carried out “a posteriori”; mean time: three weeks after the accident (extremes: one week to one year) A second battery of tests was carried out in 35%, and a third one in 8% of the patients

Adverse reactions to intravenous agents in anaesthesia in France.

Resume Dix-huit accidents anaphylactiques au suxamethonium, provenant de la region Est de la France, ont ete rassembles en 8 ans (1972–1980). Dans 15 cas, le produit responsable est l'iodure de succinylcholine, dans 3 cas le chlorure de succinylcholine. Parmi les facteurs favorisants sont retrouvees, avec une frequence significative : l'allergie medicamenteuse anterieure, la spasmophilie et l'hyperreactivite cutanee a l'histamine. 5 sujets n'auraient jamais ete anesthesies precedemment. Les signes cliniques dominants sont le collapsus cardiovasculaire (72 p. cent des cas), les signes cutaneomuqueux (72 p. cent des cas), le bronchospasme (33 p. cent des cas). Chez 5 sujets, il y eut arret cardiaque : post-anoxique dans 3 cas, primitif dans 2 cas. Le diagnostic d'anaphylaxie a ete pose sur la positivite convergente d'au moins deux des tests immuno-allergologiques specifiques (I.D. reaction a la substance a dilution 10 −5 a 10 −3 ; test de Prausnitz-Kustner avec la variante de Parish; test de degranulation des basophiles humains) ou, si un seul test etait positif, sur sa confirmation lors d'un second, ou meme d'un troisieme bilan. Ainsi, 6 malades ont eu un seul bilan, 9 en ont eu deux et 3 malades ont eu 3 bilans. L'eviction definitive du suxamethonium est indispensable en cas d'anaphylaxie vraie, ce qui impose de remettre au patient une carte d'allergie.

Choc anaphylactique au suxaméthonium A propos de 18 cas

A homogeneous series of 103 cases of shock due to muscle relaxants has been used to identify the risk factors in anaphylactoid shocks due to either true anaphylaxis or to non-specific histamine release. Clinical atopy (asthma) and sub-clinical atopy as shown up by skin tests with mites and pollens, as well as a history of IgE-dependent drug allergy, were present with a significantly greater frequency in the history of patients presenting with anaphylaxis. Abnormal histamine release and reactivity to histamine, as assessed by skin tests with 48/80 and histamine, were often found in those patients who presented with non-specific histamine release induced by muscle relaxants. Whatever the mechanism for the shock, the frequency of spasmophilia was increased. A history of non-immunological intolerance to acetyl salicylic acid and other non-steroid anti-inflammatory drugs was more often found than in the reference drugs was more often found than in the reference population. However, 25% of the patients studied did not have any of these risk factors. Several possibilities of preventing anaphylactoid reactions are given, if one or more of these risk factors are found in the history: a better choice of anaesthetic drugs, in the light of previous anaesthetic protocols, the relief of anxiety by appropriate premedication, antihistamine premedication and the prevention of bronchospasm.

S. Boileau

Papers

Adverse reactions to intravenous agents in anaesthesia in France.

Choc anaphylactique au suxaméthonium A propos de 18 cas

Facteurs de risque des réactions anaphylactoïdes aux myorelaxants. Etude rétrospective à partir de 103 chocs