Incidence and severity of anaphylactoid reactions to colloid volume substitutes
TL;DR: All available colloid volume substitutes carry the risk of anaphylactoid reactions, but the frequency of severe reactions was low for plasma-protein solutions, hydroxyethyl starch, 0-008% for dextran, and 0-038% for gelatin solutions.
About: This article is published in The Lancet.The article was published on 1977-02-26. It has received 1053 citations till now. The article focuses on the topics: Gelofusine & Hydroxyethyl starch.
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TL;DR: A simple grading system and definition of anaphylaxis has potential value for defining reaction severity in clinical practice and research settings and appears to be the major determinants of reaction severity.
Abstract: Background Existing grading systems for acute systemic hypersensitivity reactions vary considerably, have a number of deficiencies, and lack a consistent definition of anaphylaxis. Objective The aims of this study were to develop a simple grading system and definition of anaphylaxis and to identify predictors of reaction severity. Methods Case records from 1149 systemic hypersensitivity reactions presenting to an emergency department were analyzed retrospectively. Logistic regression analyses of the associations between individual reaction features and hypotension and hypoxia were used to construct a grading system. Epinephrine use, etiology, age, sex, comorbidities, and concurrent medications were then assessed for their association with reaction grade. Results Confusion, collapse, unconsciousness, and incontinence were strongly associated with hypotension and hypoxia and were used to define severe reactions. Diaphoresis, vomiting, presyncope, dyspnea, stridor, wheeze, chest/throat tightness, nausea, vomiting, and abdominal pain had weaker, albeit significant, associations and were used to define moderate reactions. Reactions limited to the skin (urticaria, erythema, and angioedema) were defined as mild. These grades correlated well with epinephrine usage. Older age, insect venom, and iatrogenic causes were independent predictors of severity. Preexisting lung disease was associated with an increased risk of hypoxia. Conclusion This simple grading system has potential value for defining reaction severity in clinical practice and research settings. The moderate and severe grades provide a workable definition of anaphylaxis. Age, reaction precipitant, and preexisting lung disease appear to be the major determinants of reaction severity.
749 citations
Cites background from "Incidence and severity of anaphylac..."
...Some authors consider cardiovascular compromise to be more severe than respiratory compromise,(4,8,9) with 1 system focusing almost entirely on the severity of cardiovascular collapse.(10,11) However, weighting cardiovascular compromise above respiratory compromise is not supported by observations that death may be due mainly to respiratory compromise, cardiovascular compromise, or both....
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TL;DR: Predictable reactions are subdivided into drug intolerance, drug idiosyncrasy, drug allergy, and pseudoallergic reactions, which are estimated to comprise approximately 80% of all ADRs.
Abstract: Adverse drug reactions (ADRs) result in major health problems in the United States in both the inpatient and outpatient setting. ADRs are broadly categorized into predictable (type A and unpredictable (type B) reactions. Predictable reactions are usually dose dependent, are related to the known pharmacologic actions of the drug, and occur in otherwise healthy individuals, They are estimated to comprise approximately 80% of all ADRs. Unpredictable are generally dose independent, are unrelated to the pharmacologic actions of the drug, and occur only in susceptible individuals. Unpredictable reactions are subdivided into drug intolerance, drug idiosyncrasy, drug allergy, and pseudoallergic reactions. Both type A and B reactions may be influenced by genetic predisposition of the patient
735 citations
TL;DR: The results of a 2-yr survey of reactions observed during anesthesia in France further corroborate the need for systematic screening in the case of anaphylactoid reaction during anesthesia and for the constitution of allergoanesthesia centers to provide expert advice to anesthesiologists and allergists.
Abstract: Background Anaphylactic and anaphylactoid reactions occurring during anesthesia remain a major cause of concern for anesthesiologists. The authors report the results of a 2-yr survey of such reactions observed during anesthesia in France. Methods Between January 1, 1999, and December 31, 2000, 789 patients who experienced immune-mediated (anaphylaxis) or nonimmune-mediated (anaphylactoid) reactions were referred to one of the 40 participating centers. Anaphylaxis was diagnosed on the basis of clinical history, skin tests, and/or specific immunoglobulin E assay. Results Anaphylactic and anaphylactoid reactions were diagnosed in 518 cases (66%) and 271 cases (34%), respectively. The most common causes of anaphylaxis were neuromuscular blocking agents (NMBAs) (n = 306, 58.2%), latex (n = 88, 16.7%), and antibiotics (n = 79, 15.1%). Rocuronium (n = 132, 43.1%) and succinylcholine (n = 69, 22.6%) were the most frequently incriminated NMBAs. Cross-reactivity between NMBAs was observed in 75.1% of cases of anaphylaxis to an NMBA. No difference was observed between anaphylactoid and anaphylactic reactions when the incidences of atopy, asthma, or drug intolerance were compared. However, atopy, asthma, and food allergy were significantly more frequent in the case of latex allergy when compared with NMBA allergy. Clinical manifestations were more severe in anaphylaxis. The positive predictive value of tryptase for the diagnosis of anaphylaxis was 92.6%; the negative predictive value was 54.3%. The diagnostic value of specific NMBA immunoglobulin E assays was confirmed. Conclusions These results further corroborate the need for systematic screening in the case of anaphylactoid reaction during anesthesia and for the constitution of allergoanesthesia centers to provide expert advice to anesthesiologists and allergists.
513 citations
TL;DR: The purpose of diagnostic procedure is to classify a sting reaction by history, identify the underlying pathogenetic mechanism, and identify the offending insect, and diagnosis of Hymenoptera venom allergy forms the basis for the treatment.
Abstract: The purpose of diagnostic procedure is to classify a sting reaction by history, identify the underlying pathogenetic mechanism, and identify the offending insect. Diagnosis of Hymenoptera venom allergy thus forms the basis for the treatment. In the central and northern Europe vespid (mainly Vespula spp.) and honeybee stings are the most prevalent, whereas in the Mediterranean area stings from Polistes and Vespula are more frequent than honeybee stings; bumblebee stings are rare throughout Europe and more of an occupational hazard. Several major allergens, usually glycoproteins with a molecular weight of 10-50 kDa, have been identified in venoms of bees, vespids. and ants. The sequences and structures of the majority of venom allergens have been determined and several have been expressed in recombinant form. A particular problem in the field of cross-reactivity are specific immunoglobulin E (IgE) antibodies directed against carbohydrate epitopes, which may induce multiple positive test results (skin test, in vitro tests) of still unknown clinical significance. Venom hypersensitivity may be mediated by immunologic mechanisms (IgE-mediated or non-IgE-mediated venom allergy) but also by nonimmunologic mechanisms. Reactions to Hymenoptera stings are classified into normal local reactions, large local reactions, systemic toxic reactions, systemic anaphylactic reactions, and unusual reactions. For most venom-allergic patients an anaphylactic reaction after a sting is very traumatic event, resulting in an altered health-related quality of life. Risk factors influencing the outcome of an anaphylactic reaction include the time interval between stings, the number of stings, the severity of the preceding reaction, age, cardiovascular diseases and drug intake, insect type, elevated serum tryptase, and mastocytosis. Diagnostic tests should be carried out in all patients with a history of a systemic sting reaction to detect sensitization. They are not recommended in subjects with a history of large local reaction or no history of a systemic reaction. Testing comprises skin tests with Hymenoptera venoms and analysis of the serum for Hymenoptera venom-specific IgE. Stepwise skin testing with incremental venom concentrations is recommended. If diagnostic tests are negative they should be repeated several weeks later. Serum tryptase should be analyzed in patients with a history of a severe sting reaction.
496 citations
Cites background from "Incidence and severity of anaphylac..."
...The most frequently used are those by Mueller (60) and by Ring and Messmer (61) (Table 2)....
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...(a) Classification of systemic reactions to insect stings by Mueller (60), (b) classification of systemic reactions modified according to Ring and Messmer (61)...
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...(a) Classification of systemic reactions to insect stings by Mueller (60), (b) classification of systemic reactions modified according to Ring and Messmer (61) (a) Grade I Generalized urticaria, itching, malaise, and anxiety Grade II Any of the above plus two or more of the following: angioedema, chest constriction, nausea, vomiting, diarrhea, abdominal pain, dizziness Grade III Any of the above plus two or more of the following: dyspnea, wheezing, stridor, dysarthria, hoarseness, weakness, confusion, feeling of impending disaster Grade IV Any of the above plus two or more of the following: fall in blood pressure, collapse, loss of consciousness, incontinence, cyanosis (b) Grade I Generalized skin symptoms (e.g. flush, generalized urticaria, angioedema) Grade II Mild to moderate pulmonary, cardiovascular, and/or gastrointestinal symptoms Grade III Anaphylactic shock, loss of consciousness Grade IV Cardiac arrest, apnea Time interval between stings, number of stings....
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...Ring J, Messmer K. Incidence and severity of anaphylactoid reactions to colloid volume substitutes....
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References
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Journal Article•
TL;DR: An appraisal is made of toxic, microbiogenic, and allergic side effects occurring in man as a result of large amounts of penicillin increasingly used in medical and veterinary practice, including a study of 151 anaphylactic fatalities reported to have followedPenicillin administration.
Abstract: An appraisal is made of toxic microbiogenic and allergic side effects occurring in man as a result of large amounts of penicillin increasingly used in medical and veterinary practice The allergic reactions constitute the most common and significant side effects of penicillin The major antigenic determinant in penicillin allergy the penicilloyl group derived from the penicillanic acid nucleus is common to all penicillins and explains at least in part the cross-reactivity of man to any penicillin derivative or preparation Available data do not permit conclusions as to the true frequency of allergic reactions to penicillin which are reported to vary from 07-10% in different studies in different countries Among the side effects the anaphylactic type may occur in about 0015-0004% with a fatality rate from shock of 00015-0002% among treated patients There is no convincing evidence that the frequency of allergic side effects to penicillin has increased in the last 10 years in relation to the increasing worldwide use of penicillin Persons in contact with penicillin may respond by producing antibodies the presence of which can be determined by immunological procedures and these are believed to be partly responsible for sudden penicillin side reactions Routine prospective skin testing prior to penicillin administration cannot however be generally advocated at present but in special instances it can be undertaken in cooperation with specialists and competent laboratories The present investigation includes a study of 151 anaphylactic fatalities reported to have followed penicillin administration Of these persons 14% had evidence of previous allergies of some kind 70% had received penicillin previously and 1/3 of these had already experienced prior sudden allergic reactions In most of these fatal cases the symptoms leading to death occurred within 15 minutes An Expert Committee of the World Health Organization has emphasized that most anaphylactic fatalities can be prevented by measures to reduce penicillin sensitization environmentally in the population on the 1 hand and by the preparedness of doctors on the other (authors modified) (summary in FRE)
486 citations
TL;DR: Histamine release was always associated with Haemaccel infusion and corresponded in extent to the clinical symptoms observed, but there was no significant histamine release associated with the reactions to dextran.
Abstract: Histamine release by modified gelatin (Haemaccel) and dextran (Macrodex) has been demonstrated in volunteers by direct and indirect methods. In a pilot study of Haemaccel, histamine release was observed in six of seven volunteers. The highest plasma histamine concentration was 4.8 ng/ml, the lowest 1.7 ng/ml: two of the subjects showed slight allergic reactions. Using Haemaccel batch 2551, 10 out of 12 subjects reacted to the rapid infusion of Haemaccel with increased plasma histamine concentrations, whereas none reacted to Ringer's solution. None of the 10 subjects had an allergic reaction, but an increase in gastric secretion was observed in eight. Changes in the venous basophil granulocyte count were found in both those who reacted and those who did not react to Haemaccel. After the rapid infusion of dextran the highest plasma histamine concentration was 5.0 ng/ml, the lowest 1.3 ng/ml. The withdrawal of blood had no influence on plasma histamine concentration. The incidences of histamine release produced by Haemaccel varied with different batches. Thus, it seems unlikely that immunological mechanisms are principally responsible. Nine instances of allergic and anaphylactoid reactions to plasma substitutes have been reported, seven after Haemaccel infusion, and two after dextran administration. One of the patients who received dextran died. Histamine release was always associated with Haemaccel infusion and corresponded in extent to the clinical symptoms observed, but there was no significant histamine release associated with the reactions to dextran.
96 citations
TL;DR: The hypothesis that HES infusion causes and augmentation of serum alpha-amylase concentrations in man was confirmed and should be borne in mind when HES solutions are given to patients in whom the diagnosis of acute pancreatitis might be considered.
Abstract: In two groups, each consisting of five healthy volunteers, 7 ml blood/kg body weight were exchanged with equal amounts of hydroxyethyl starch (HES) and dextran 60 solutions, respectively. Dextran 60 plasma levels, determined by the anthrone method, were undetectable after 4 weeks. The elimination of HES from the blood, determined by an immunological technique and by the anthrone method, had a very protracted course. Two weeks after infusion the HES plasma concentrations were 9% of the initial value and after 17 weeks they were still above the l% level. The prolonged intravascular persistence of HES in its commercially available preparation, and the possibility of tissue accumulation after repeated HES infusions were considered undesirable. The hypothesis that HES infusion causes an augmentation of serum α-amylase concentrations in man was confirmed. This effect should be borne in mind when HES solutions are given to patients in whom the diagnosis of acute pancreatitis might be considered.
85 citations
TL;DR: Incompatibility reactions due to hydroxyethyl starch (HES) were observed during 8 out of 10,273 infusions of 500 ml 6% HES (Plasmasteril) and specific antibodies against HES were, however, not detected.
Abstract: Incompatibility reactions due to hydroxyethyl starch (HES) were observed during 8 out of 10,273 infusions of 500 ml 6% HES (Plasmasteril®). The clinical symptoms ranged from skin reactions to tachycar
48 citations
01 Jan 1970
TL;DR: Measurement of the blood histamine levels as well as the circulatory effects could be modified by the previous administration of anti-histaminic drugs indicate that the hypotension observed following the rapid infusion of gelatine solutions is due to the release of histamine.
Abstract: In a series of 133 dogs, 10–20 ml/kg arterial blood were removed and replaced by rapid intravenous infusion of an equivalent volume of various plasma substitutes. Following the infusion of gelatine solutions, an acute fall in arterial blood pressure was observed, but not following the infusion of equal quantities of Dextran 60 or of 0.9% NaCl solution. Measurement of the blood histamine levels as well as the fact that the circulatory effects could be modified by the previous administration of anti-histaminic drugs indicate that the hypotension observed following the rapid infusion of gelatine solutions is due to the release of histamine. Since histamine liberation has also been shown in preliminary studies in man, rapid infusions of gelatine solutions should be avoided in clinical practice, or patients receiving them should be pre-treated with anti-histaminic drugs.
38 citations