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Perioperative Anaphylaxis: Evaluation and Management

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Abstract

Perioperative anaphylaxis (PA) is a rare but life-threatening condition that poses diagnostic and management challenges in the operating room. The incidence of severe perioperative reactions is estimated to be approximately 1:7000–10,000. Management involves both immediate stabilization of the patient and identifying the culprit agent. Identification is essential to prevent recurrence of the event in subsequent surgeries and to avoid unnecessary labeling of drug allergy. Identifying all possible exposures including medications, disinfectants, latex, and dyes and choosing the appropriate tests are essential for proper evaluation. To identify the culprit, primary testing modalities include tryptase at the time of the reaction with subsequent levels and skin testing with nonirritating concentrations to the medications and substances utilized during the procedure and those potentially used as alternates. This strategy provides guidance for future surgeries and procedures. Close collaboration between the allergy, anesthesiology, and surgery teams is essential for appropriate management of these patients at the time of the reaction, during the post event evaluation and in preparation for subsequent surgeries.

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Abbreviations

PA :

Perioperative anaphylaxis

POH:

Perioperative hypersensitivity

US:

United States of America

ASA:

American Society of Anesthesiologists

ACE:

Angiotensin converting enzyme

IgE:

Immunoglobulin E

NAP6:

National Audit Project 6

PAGS:

Perioperative Anaphylaxis Grading System

ISPAR:

International Suspected Perioperative Allergy Group

IV:

Intravenous

SC:

Subcutaneous

NMBA:

Neuromuscular blocking agents

UK:

United Kingdom

MRGPRX2:

MAS Related GPR Family Member X2

HIV:

Human immunodeficiency virus

Hev b:

Hevea brasiliensis

FDA:

Food and Drug Administration

SPT:

Skin prick test

IDT:

Intradermal testing

IDHR:

Immune-mediated drug hypersensitivity reaction

DPT :

Drug provocation test

NSAID:

Non-steroidal anti-inflammatory drugs

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    Deepti Vellaichamy Manian & Gerald W Volcheck

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Manian, D.V., Volcheck, G.W. Perioperative Anaphylaxis: Evaluation and Management. Clinic Rev Allerg Immunol 62, 383–399 (2022). https://doi.org/10.1007/s12016-021-08874-1

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