Perioperative Management of Anaphylaxis

Anaphylaxis, a severe, potentially life-threatening allergic reaction, can occur during surgery in response to anesthesia or other medications used during an operation. The most common causes of intraoperative anaphylaxis are neuromuscular blocking agents (NMBAs), antibiotics, disinfectants, and latex (1). Evaluating the type of reaction and understanding the subsequent allergy evaluation of possible causes are crucial for the management of a patient experiencing perioperative anaphylaxis and for the prevention of additional episodes.  

During the perioperative timeframe, the occurrence of anaphylaxis can vary, based on comorbidities, medications, surgical procedures, and anesthetics. In addition, delay in diagnosis can occur because of the setting – the patient is usually intubated, sedated, and draped, and so early signs and symptoms are not easily observed. Furthermore, anesthetics can cause cardiovascular changes that can mimic early anaphylaxis by increasing heart rate or causing a decrease in arterial pressure, making early recognition even more challenging (2).  

Clinical manifestations of anaphylactic response to anesthesia or other perioperative medications can vary from a mild rash to cardiovascular collapse. Early symptoms of anaphylaxis include low blood pressure and an abnormally high heart rate. The identification of the culprit can sometimes be deduced according to the timing between the administration of the suspected allergen and the clinical signs and symptoms that erupt. For instance, when symptoms occur within the first 30 minutes of anesthesia, a suspected culprit is NMBAs, whereas when symptoms occur after 30 minutes of anesthesia, latex is considered as a possible inducer (3). 

Management of anaphylaxis should first and foremost consider a careful and complete review of the clinical and perioperative history before any procedure in patients with previous perioperative reaction, especially because these patients are more likely to experience a reaction during subsequent exposures. Thus, it is crucial for concerns to be discussed between the anesthesia and surgical teams and that an allergy consult be obtained if there is an allergic reaction (3). 

The management of anaphylaxis should also involve a careful review of the treatment administered and the response of the patient. It is important to document even the substances used in the procedure that are not typically allergenic, including antiseptics, gels, dyes, and hemostatic agents.  

There are no randomized studies that have evaluated the use of a specific protocol of premedication for the prevention of perioperative anaphylaxis (4). So, most importantly, anesthesiologists and allergist teams should evaluate at-risk patients before any surgical procedure and identify any potential causes of anaphylaxis. Prevention is the most important component to decrease the incidence of anaphylaxis, which begins with recognition and documentation. 

Sources: 

1. Mertes PM, Lambert M, Gueant-Rodriguez RM, Aimone-Gastin I, MoutonFaivre C, Moneret-Vautrin DA, et al. Perioperative anaphylaxis. Immunol Allergy Clin N Am 2009;29:429-51. 

2. Bailey JM. Context-sensitive half-times and other decrement times of inhaled 

anesthetics. Anesth Analg 1997;85:681-6. 

3. Volcheck GW, Hepner DL. Identification and Management of Perioperative Anaphylaxis. J Allergy Clin Immunol Pract. 2019;7(7):2134-2142. doi:10.1016/j.jaip.2019.05.033 

4. Mertes PM, Malinovsky JM, Jouffroy L, Working Group of the SFAR and SFA, Aberer W, Terreehorst I, et al. Reducing the risk of anaphylaxis during anesthesia: 2011 updated guidelines for clinical practice. J Investig Allergol Clin Immunol 2011;21:442-53.