Incidence and clinical importance of perioperative histamine release: randomised study of volume loading and antihistamines after induction of anaesthesia
TL;DR: The histamine-related disturbances under anaesthesia were remarkable for their severity (even with small rises in histamine concentrations), for the prevalence of bradycardia, and for the absence of skin signs.
About: This article is published in The Lancet.The article was published on 1994-04-16 and is currently open access. It has received 136 citations till now. The article focuses on the topics: Antihistamine & Haemaccel.
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TL;DR: This research presents a novel and scalable approach called “SmartLabeling” that allows for real-time assessment of the severity of adverse events before and after they occur and its application in the clinical practice.
Abstract: Crystalloids and different component colloids, used for volume resuscitation, are sometimes associated with various adverse effects. Clinical trial findings for such fluid types in different patients’ conditions are conflicting. Whether the mortality benefit of balanced crystalloid than saline can be inferred from sepsis to other patient group is uncertain, and adverse effect profile is not comprehensive. This study aims to compare the survival benefits and adverse effects of seven fluid types with network meta-analysis in sepsis, surgical, trauma, and traumatic brain injury patients. Searched databases (PubMed, EMBASE, and Cochrane CENTRAL) and reference lists of relevant articles occurred from inception until January 2020. Studies on critically ill adults requiring fluid resuscitation were included. Intervention studies reported on balanced crystalloid, saline, iso-oncotic albumin, hyperoncotic albumin, low molecular weight hydroxyethyl starch (L-HES), high molecular weight HES, and gelatin. Network meta-analyses were conducted using random-effects model to calculate odds ratio (OR) and mean difference. Risk of Bias tool 2.0 was used to assess bias. Confidence in Network Meta-Analysis (CINeMA) web application was used to rate confidence in synthetic evidence. Fifty-eight trials (n = 26,351 patients) were identified. Seven fluid types were evaluated. Among patients with sepsis and surgery, balanced crystalloids and albumin achieved better survival, fewer acute kidney injury, and smaller blood transfusion volumes than saline and L-HES. In those with sepsis, balanced crystalloids significantly reduced mortality more than saline (OR 0.84; 95% CI 0.74–0.95) and L-HES (OR 0.81; 95% CI 0.69–0.95) and reduced acute kidney injury more than L-HES (OR 0.80; 95% CI 0.65–0.99). However, they required the greatest resuscitation volume among all fluid types, especially in trauma patients. In patients with traumatic brain injury, saline and L-HES achieved lower mortality than albumin and balanced crystalloids; especially saline was significantly superior to iso-oncotic albumin (OR 0.55; 95% CI 0.35–0.87). Our network meta-analysis found that balanced crystalloids and albumin decreased mortality more than L-HES and saline in sepsis patients; however, saline or L-HES was better than iso-oncotic albumin or balanced crystalloids in traumatic brain injury patients. PROSPERO website, registration number: CRD42018115641).
40 citations
TL;DR: Patients should be trained with regard to the nature of anaphylaxis, the major eliciting agents and the principles of behavior and coping with the situation including the handling of epinephrine autoinjectors and the application of antianaphylactic medication.
Abstract: Anaphylaxis is the maximal variant of an acute life-threatening immediate-type allergy. Due to its often dramatic onset and clinical course, practical knowledge in the management of these reactions is mandatory both for physicians and patients. It has to be distinguished between acute treatment modalities and general recommendations for management of patients who have suffered from an anaphylactic reaction. Acute treatment comprises general procedures like positioning, applying an intravenous catheter, call for help, comfort of the patient as well as the application of medication. The acute treatment modalities are selected depending upon the intensity of the clinical symptomatology as they are categorized in 'severity grades'. First of all it is important to diagnose anaphylaxis early and consider several differential diagnoses. This diagnosis is purely clinical and laboratory tests are of no help in the acute situation. Epinephrine is the essential antianaphylactic drug in the pharmacologic treatment. It should be first applied intramuscularly, only in very severe cases or under conditions of surgical interventions intravenous application can be tried. Furthermore, glucocorticosteroids are given in order to prevent protracted or biphasic courses of anaphylaxis; they are of little help in the acute treatment. Epinephrine autoinjectors can be used by the patient him/herself. Histamine H(1)-antagonists are valuable in mild anaphylactic reactions; they should be given intravenously if possible. The replacement of volume is crucial in antianaphylactic treatment. Crystalloids can be used in the beginning, in severe shock colloid volume substitutes have to be applied. Patients suffering from an anaphylactic episode should be observed over a period of 4-10 h according to the severity of the symptomatology. It is crucial to be aware or recognize risk patients as for example patients with severe uncontrolled asthma, or under beta-adrenergic blockade. When bronchial symptoms are in the focus, inhaled beta(2)-agonists can be tried, also for laryngeal edema. The use of combined H(1)- and H(2)-antagonists has been recommended for prophylaxis prior to application of potentially anaphylaxis-eliciting drugs (e.g. radiographic contrast media). Patients who have survived an anaphylactic reaction have to be thoroughly examined and an allergy diagnosis has to be performed with regard to the eliciting agent and the pathogenic mechanism involved. In cases of clear-cut IgE-mediated anaphylaxis, allergen-specific immunotherapy is available for some allergens and helpful as for example for insect venom anaphylaxis. Furthermore, patients should be trained with regard to the nature of anaphylaxis, the major eliciting agents and the principles of behavior and coping with the situation including the handling of epinephrine autoinjectors and the application of antianaphylactic medication. Educational programs for anaphylaxis have been developed.
35 citations
TL;DR: In this chapter, colloid characteristics are related to the clinical efficacy of different colloidal preparations for intentional haemodilution and plasma volume support in patients with vascular disease or acute ischaemic stroke.
Abstract: Maintenance/achievement of normovolaemia, haemodynamic stability and adequate nutritive blood flow is the main objective of clinical fluid treatment. These goals are more effectively reached with the choice of artificial colloids rather than balanced salt solutions for plasma volume support. Commonly used artificial colloids are dextrans, gelatins and different hydroxyethyl starch (HES) preparations, including pentastarch and pentafractions of HES. With the choice of colloid, the plasma volume expanding efficacy, intravascular persistence, haemorheologic effectiveness and inherent specific pharmacological effects on haemostasis, red cell aggregation, platelet function, plasma viscosity and blood corpuscle-endothelial cell interactions of the colloid should be considered. In this chapter, colloid characteristics are related to the clinical efficacy of different colloidal preparations for intentional haemodilution and plasma volume support in patients with vascular disease or acute ischaemic stroke. Furthermore, the choice of colloid for perioperative fluid therapy and resuscitation of shock and trauma conditions is considered.
33 citations
TL;DR: A case of anaphylaxis to cisatracurium following a negative skin test is presented and the absence of a clearly identified triggering agent increases the difficulties facing the anaesthetist.
Abstract: General anaesthesia for the patient with a history of anaesthesia-related anaphylaxis is challenging. Precautions against anaphylaxis and the use of skin test negative drugs can reduce but not eliminate the risk. In the majority of such cases, subsequent anaesthesia is uneventful. However, the absence of a clearly identified triggering agent increases the difficulties facing the anaesthetist. We present a case of anaphylaxis to cisatracurium following a negative skin test.
32 citations
TL;DR: This study design differs from other trials on preoperative prophylaxis and postoperative recovery, and has been developed to try a new concept and avoid previous failures.
Abstract: General design: Presentation of a new type of a study protocol for evaluation of the effectiveness of an immune modifier (rhG-CSF, filgrastim): prevention of postoperative infectious complications and of sub-optimal recovery from operation in patients with colorectal cancer and increased preoperative risk (ASA 3 and 4). This part describes the design of the randomised, placebo controlled, double-blinded, single-centre study performed at an university hospital (n = 40 patients for each group).¶Objective: The trial design includes the following elements for a prototype protocol:¶ - The study population is restricted to patients with colorectal cancer, including a left sided resection and an increased perioperative risk (ASA 3 and 4).¶ - Patients are allocated by random to the control or treatment group.¶ - The double blinding strategy of the trial is assessed by psychometric indices.¶ - An endpoint construct with quality of life (EORTC QLQ-C30) and a recovery index (modified Mc Peek index) are used as primary endpoints. Qualitative analysis of clinical relevance of the endpoints is performed by both patients and doctors.¶ - Statistical analysis uses an area under the curve (AUC) model for improvement of quality of life on leaving hospital and two and six months after operation. A confirmatory statistical model with quality of life as the first primary endpoint in the hierarchic test procedure is used. Expectations of patients and surgeons and the negative affect are analysed by social psychological scales.¶Conclusion: This study design differs from other trials on preoperative prophylaxis and postoperative recovery, and has been developed to try a new concept and avoid previous failures.¶
32 citations
Cites background or methods from "Incidence and clinical importance o..."
...Low-dose heparin will be administered in the morning before operation, as well as colloidal and cristalloid volume substitution according to clinical rules and on-demand, a strategy to minimise blood transfusion, and antihistamine H1- + H2-prophylaxis with 0.1 mg/kg dimetindene and 5 mg/kg cimetidine i.v. at least 15 min before induction of anaesthesia [33, 54]....
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...The decision of the dose of filgrastim, route, administration frequency and possible combination with antibiotics, heparin, volume substitution and antihistamines [33] used in the planned trial is based on three components:...
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...It has worked in three other situations [33, 51, 52] also including up to 16 escape clauses....
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...Such selection needs particular care in the ASA classification that must follow the rules developed for surgical trials [44] and be performed by a trained study anaesthetist, because anaesthetists on duty are biased towards higher ASA classes (as based on the results obtained in the MainzMarburg trial [33])....
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...at least 15 min before induction of anaesthesia [33, 54]....
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References
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Journal Article•
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2,147 citations
TL;DR: 80 reports of randomised clinical trials in four leading general medical journals were reviewed and the reporting of the methodology of randomisation was inadequate, and the handling of comparisons of baseline characteristics was inadequate.
473 citations
TL;DR: The electrocardiographic changes consistent with ischemia during the 4 day perioperative period were documented and characterized in 100 patients with or at risk for coronary artery disease undergoing noncardiac surgery and postoperative ischemic episodes were the most severe.
321 citations
TL;DR: Pancuronium is suggested to be the least likely currently available agent to provoke a major anaphylactoid reaction and Predisposing factors in patients sensitive to muscle relaxants were: female sex, previous allergy and atopy.
Abstract: Sixty one patients who had suffered intra-operative anaphylactoid reactions were studied. Intradermal testing identified the causative agent in 84% of cases and, in 75% of these, muscle relaxants were responsible. Predisposing factors in patients sensitive to muscle relaxants were: female sex, previous allergy and atopy. The incidence of previous exposure was considerably higher than that reported in the literature. Pancuronium is suggested to be the least likely currently available agent to provoke a major anaphylactoid reaction.
130 citations
TL;DR: The effects of increasing concentrations of three opioids were studied on the release of preformed and de novo synthesized chemical mediators from human peripheral blood basophils and mast cells isolated from skin tissues or lung parenchyma.
Abstract: Opioids differ in their capacity to cause release of histamine. The effects of increasing concentrations of three opioids (morphine, buprenorphine, and fentanyl) were studied on the release of preformed (histamine and tryptase) and de novo synthesized (prostaglandin D2 [PGD2] and peptide-leukotriene C4 [LTC4]) chemical mediators from human peripheral blood basophils and mast cells isolated from skin tissues or lung parenchyma. Basophils released < 5% of their histamine content and did not synthesize significant amounts of LTC4 when incubated with any of the opioids. Mast cells showed markedly different responses to the three opioids. Morphine (10(-5)-3 x 10(-4) M), in a concentration-dependent manner, induced histamine and tryptase release from skin but not from lung mast cells, up to a maximum of 18.2 +/- 1.9% and 13.0 +/- 4.1 micrograms/10(7) cells, respectively. Morphine did not induce de novo synthesis of PGD2 from skin mast cells. Buprenorphine (10(-6)-10(-4) M), in a concentration-dependent manner, caused histamine and tryptase release from lung but not from skin mast cells, to a maximum of 47.6 +/- 7.2% and 35.1 +/- 13.6 micrograms/10(7) cells, respectively. Buprenorphine also induced de novo synthesis of PGD2 and LTC4 from lung mast cells. Fentanyl (10(-5)-10(-3) M) did not induce histamine and tryptase release or the de novo synthesis of PGD2 or LTC4 from any mast cells. Histamine release caused by buprenorphine from lung mast cells was slow (t1/2 = 11.2 +/- 3.6 min) compared with that induced by morphine from skin mast cells (t1/2 < 1 min, P < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)
113 citations