1 / 39

Anaphylaxis

Anaphylaxis. Dr. S. Parthasarathy MD., DA., DNB( anaes ), MD ( Acu ), Dip. Diab . DCA, Dip. Software statistics PhD ( physio ) Mahatma Gandhi medical college and research institute , puducherry – India . Definition .

blade
Télécharger la présentation

Anaphylaxis

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Anaphylaxis Dr. S. Parthasarathy MD., DA., DNB(anaes), MD (Acu), Dip. Diab. DCA, Dip. Software statistics PhD (physio) Mahatma Gandhi medical college and research institute , puducherry – India

  2. Definition • Anaphylaxis is an acute reaction leading to severe physiologic derangements of multiple systems. • Follows the administration of allergen to a sensitized individual • True anaphylaxis denotes an IgE antibody- mediated reaction • Non IgE antibody- mediated reaction resembling anaphylaxis is anaphylactoid reaction

  3. Why should there be a name like that ?? • Inj TT – protects further tetanus disease • This is prophylaxis • Portierand Richet in 1902 reported that the second injection of sea anemone extract into dogs resulted in a fatal systemic reaction • Iron inj. -- First time – ok – on second injection It is fatal = antagonistic of prophylaxis – anaphylaxis

  4. Histamine release but not anaphylaxis • Morphine • Skin alone ?? • Atracurium • Skin and lungs also ??

  5. Why are some of us destined for a lifeof allergy and others not? • Low grade responders • Ige antibodies less with interferons • High grade responders • Ige antibodies more with cytokines

  6. Incidence in anaesthesia • It varies • 2 in 10,000 to 4.5 in 10000 • In france single institution study – 16 in 10000

  7. Clinical manifestationsof anaphylaxis • IV antigen ----= starts in 5 minutes • Other routes like oral • Slower and less rapid progression

  8. Clinical tips – may not be severe • Already asthmatic - • Already on beta blockers • Ill health

  9. Grades of clinical signs • Grade I presence of cutaneous signs; (10%) • Grade II as presence of measurable but not life-threatening symptoms including cutaneous effects, arterial hypotension(22%) • Grade III as presence of a life-threatening reaction, collapse , severe bronchospasm, arrhythmias ,(66 %) • Grade IV cardiac and/or respiratory arrest (4%)

  10. Anaesthesia • symptoms -- Cutaneous, respiratory, CVS, GI • Single system involvement – overlooked • During general and regional anesthesia or during deep sedation, cardiovascular signs predominate Epidural hypotension –give colloids – anaphylaxis to colloids --- Gloom ??

  11. Anaphylaxis under anaesthesiais not routine — most common triggers • It is not community anaphylaxis like – • Food stuff • Bee sting • Wasps • Snake bites • What happens in anaesthesia ?? • Unconscious !!

  12. Anaesthesia – confounding • During general anaesthesia, early symptoms of anaphylaxis such as tongue swelling, itch, breathing difficulty and wheeze • Skin lesions under the drapes

  13. Differential diagnosis • In a conscious patient, anaphylaxis is most easily confused with a vasovagal reaction, which may occur when a patient collapses after an injection or painful procedure • But there is a bradycardiain a vasovagal reaction

  14. Differential diagnosis • cold urticaria (especially if generalized), idiopathic urticaria, carcinoid tumors, and systemic mastocytosis. • Symptom based DD

  15. Who are prone ?? • Females • Previous anaphylaxis • patients with spina bifida or allergy to some fruit- latex allergy • IgA deficiency- blood and colloids

  16. TREATMENT OF ANAPHYLAXIS • Initial • Secondary

  17. Initial • Remove the offender • Venous tourniquet • Airway maintenance with 100% oxygen • laryngeal edema -- aerosolized epinephrine epinephrine by nebulizer (8–15 drops of 2.25% epinephrine in 2 mL normal saline) • Large bore IV lines • intravascular volume should be maintained with administration of isotonic crystalloid

  18. Rapid infusion of an initial bolus of 1–2 L intravenous fluid initially (20 mL/kg initially in children) before reassessment. • Adults may require 2–5 L.

  19. Epinephrine

  20. severe hypotension or airway obstruction • 0.1-mL (100μ g of a 1:1000 dilution) increments of epinephrine should be given intravenously, usually not exceeding 0.5 mg total. • Beware – halothane, stroke, infarction

  21. NO IV access • 0.3 mL of 1:1000 epinephrine can be given subcutaneously or intramuscularly, or 10 mL of 1:10,000 epinephrine can be administered through the endotracheal tube. • Hypotension and bronchospasm • Norad, dopamine infusions to follow

  22. Secondary • Antihistaminics – diphenhydramine • Ranitidine 1 mg/ kg • Steroids : hydrocortisone- 5 mg/kg (up to 200 mg initial dose) and then 2.5 mg/kg every 6 hours- methylprednisolone 1 mg/ kg initially and every 6 hours IV aminophylline infusion • Bicarbonate – controversial

  23. Refractory hypotension • Glucagon may be administered as a 1–5 mg (20–30 μg/kg in children, maximum 1 mg) dose over 5 min followed by an infusion of 5–15 μg/ min Recently – vasopressin

  24. Diagnosis • Mast cell tryptase • Postmortem collection of samples for assay is also possible • 2 tubes 5 – 10 ml – 6 hours gap within 48 hours means 4 deg • Or – 20 deg.

  25. Diagnosis • Immunodiagnostic Tests • Intradermal skin tests still are the most readily available and generally useful diagnostic tests for drug allergy. Total Serum IgE Levels • Assays to Measure Complement Activation • Blood and urine assay of histamine mediators • Radioallergosorbent Testing

  26. Perioperative environment

  27. NeuromuscularBlocking Agents • Suxamethonium • Pancuronium, atracurium, alcuronium

  28. Opioids • Histamine release is common Morphine and pethidine • anaphylaxis are rare • NSAIDs • Penicillin and betalactams, cephalosporins, septran • Skin test is almost foolproof to avoid it.

  29. Radiocontrast • Urticaria, angioedema, wheezing, dyspnea, hypotension, or death occurs in 2–3% of patients receiving intravenous or intraarterial infusions. Oral prednisolone, with AH prior to IV contrast

  30. Local anaesthetics • Genuine allergic reactions to local anaesthetic agents are extremely rare • Preservatives

  31. Colloids • Clinical anaphylaxis to all groups of colloids is possible, including gelatins (such as Haemaccel® and Gelofusine®), albumin, dextrans and starches. • Dextrans proved

  32. Methylmethacrylate • Episodes of hypotension , tachycardia reported • Whether anaphylaxis – proved ?? • Protamine • Diabetics – use insulin protamine

  33. Induction agents • Propofol was originally formulated in a vehicle containing Cremophor® EL but was reformulated as a lipid emulsion following reports of severe allergic reactions. Egg allergy ?? Thiopentone reported , methohexital – no

  34. Transfusion-RelatedAnaphylaxis In GA • Refractory unexplained hypotension • Haematuria

  35. Natural Rubber Latex • Children with spina bifida and urogenital anomalies • Gloves • Ambu bag • Reservoir bags • Masks • Latex injection ports • Tourniquets • Blood pressure cuffs

  36. Summary • Definition ,mechanism , incidence • Clinical manifestations • Differential diagnosis • Lab • Treatment • Anaesthetic factors and tips

  37. Thank you all

More Related