Management of suspected immediate perioperative allergic reactions: an international overview and consensus recommendations

Lene H Garvey; Pascale Dewachter; David L Hepner; Paul Michel Mertes; Susanna Voltolini; Russell Clarke; Peter Cooke; Tomaz Garcez; Anne Berit Guttormsen; Didier G Ebo; Philip M Hopkins; David A Khan; Peter Kopac; Mogens Krøigaard; Jose Julio Laguna; Stuart Marshall; Peter Platt; Michael Rose; Vito Sabato; Paul Sadleir; Louise Savic; Sinisa Savic; Kathrin Scherer; Tomonori Takazawa; Gerald W Volcheck; Helen Kolawole

doi:10.1016/j.bja.2019.04.044

Management of suspected immediate perioperative allergic reactions: an international overview and consensus recommendations

Br J Anaesth. 2019 Jul;123(1):e50-e64. doi: 10.1016/j.bja.2019.04.044. Epub 2019 May 24.

Authors

Lene H Garvey¹, Pascale Dewachter², David L Hepner³, Paul Michel Mertes⁴, Susanna Voltolini⁵, Russell Clarke⁶, Peter Cooke⁷, Tomaz Garcez⁸, Anne Berit Guttormsen⁹, Didier G Ebo¹⁰, Philip M Hopkins¹¹, David A Khan¹², Peter Kopac¹³, Mogens Krøigaard¹⁴, Jose Julio Laguna¹⁵, Stuart Marshall¹⁶, Peter Platt⁶, Michael Rose¹⁷, Vito Sabato¹⁰, Paul Sadleir¹⁸, Louise Savic¹⁹, Sinisa Savic²⁰, Kathrin Scherer²¹, Tomonori Takazawa²², Gerald W Volcheck²³, Helen Kolawole¹⁶

Affiliations

¹ Danish Anaesthesia Allergy Centre, Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital, Gentofte, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark. Electronic address: lene.heise.garvey@regionh.dk.
² Service d'Anesthésie-Réanimation, Groupe Hospitalier de Paris-Seine-Saint-Denis, Assistance Publique-Hôpitaux de Paris, Paris, France; Université Paris 13, Sorbonne-Paris-Cité, Paris, France.
³ Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
⁴ Department of Anesthesia and Intensive Care, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, Strasbourg, France.
⁵ Allergy Unit, Policlinic Hospital San Martino, Genoa, Italy.
⁶ Department of Anaesthesia, Sir Charles Gairdner Hospital, Western Australia, Australia; Anaesthetic Allergy Referral Centre of Western Australia, Australia.
⁷ Department of Anaesthesia and Perioperative Medicine, Auckland City Hospital, Auckland, New Zealand.
⁸ Department of Immunology, Manchester University NHS Foundation Trust, Manchester, UK.
⁹ Department of Anaesthesia and Intensive Care, Haukeland University Hospital and Department of Clinical Medicine, University of Bergen, Bergen, Norway.
¹⁰ Department of Immunology, Allergology and Rheumatology, University of Antwerp, Antwerp University Hospital, Belgium.
¹¹ Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK.
¹² Department of Internal Medicine, Division of Allergy & Immunology, University of Texas Southwestern Medical Center, Dallas, TX, USA.
¹³ University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia.
¹⁴ Danish Anaesthesia Allergy Centre, Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital, Gentofte, Denmark.
¹⁵ Allergy Unit, Allergo-Anaesthesia Unit, Hospital Central de la Cruz Roja, Faculty of Medicine, Alfonso X El Sabio University, ARADyAL, Madrid, Spain.
¹⁶ Department of Anaesthesia and Perioperative Medicine, Monash University, Melbourne, Australia; Department of Anaesthesia, Peninsula Health, Melbourne, Australia.
¹⁷ Department of Anaesthesia, Royal North Shore Hospital, University of Sydney, Sydney NSW, Australia.
¹⁸ Department of Anaesthesia, Sir Charles Gairdner Hospital, Western Australia, Australia; Anaesthetic Allergy Referral Centre of Western Australia, Australia; Department of Pharmacology, University of Western Australia, Australia.
¹⁹ Anaesthetic Department, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
²⁰ Department of Clinical Immunology and Allergy, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
²¹ Allergy Unit, Department of Dermatology, University Hospital Basel, Basel University, Basel, Switzerland.
²² Intensive Care Unit, Gunma University Hospital, Maebashi, Gunma, Japan.
²³ Division of Allergic Diseases, Mayo Clinic College of Medicine, Rochester, MN, USA.

PMID: 31130272
DOI: 10.1016/j.bja.2019.04.044

Abstract

Suspected perioperative allergic reactions are rare but can be life-threatening. The diagnosis is difficult to make in the perioperative setting, but prompt recognition and correct treatment is necessary to ensure a good outcome. A group of 26 international experts in perioperative allergy (anaesthesiologists, allergists, and immunologists) contributed to a modified Delphi consensus process, which covered areas such as differential diagnosis, management during and after anaphylaxis, allergy investigations, and plans for a subsequent anaesthetic. They were asked to rank the appropriateness of statements related to the immediate management of suspected perioperative allergic reactions. Statements were selected to represent areas where there is a lack of consensus in existing guidelines, such as dosing of epinephrine and fluids, the management of impending cardiac arrest, and reactions refractory to standard treatment. The results of the modified Delphi consensus process have been included in the recommendations on the management of suspected perioperative allergic reactions. This paper provides anaesthetists with an overview of relevant knowledge on the immediate and postoperative management of suspected perioperative allergic reactions based on current literature and expert opinion. In addition, it provides practical advice and recommendations in areas where consensus has been lacking in existing guidelines.

Keywords: Delphi process; allergy; anaesthesia; epinephrine; guideline; hypersensitivity reaction; perioperative anaphylaxis; testing.

Publication types

Consensus Development Conference

MeSH terms

Humans
Hypersensitivity, Immediate / diagnosis
Hypersensitivity, Immediate / therapy*
Internationality
Intraoperative Complications / diagnosis
Intraoperative Complications / therapy*
Postoperative Complications / diagnosis
Postoperative Complications / therapy*