Culprit allergen prevalence in polyreactive individuals reflects prescription trends: A tool for estimating comparative anaphylaxis risk using the example of neuromuscular blocking agents.

Prescription-event monitoring (PEM) is the current gold standard for determining the risk of rare drug side-effects and comparing the risk between agents; however, spontaneous or prompted reporting schemes have low case-detection rates and exposure may be difficult to estimate. A novel method is described that allows a comparative adverse event rate between two drugs to be estimated-based on patterns of cross-reactivity-requiring only a sample of cases and no direct knowledge of drug exposure rates. Agreement was compared between the novel method and historical estimates of risk using PEM for comparative risk of rocuronium versus vecuronium anaphylaxis.

Agreement of a clinical scoring system with allergic anaphylaxis in suspected perioperative hypersensitivity reactions: prospective validation of a new tool.

Background: A clinical scoring system to estimate the likelihood that a reaction represents a perioperative immediate hypersensitivity reaction has been devised using a Delphi consensus process. Agreement of this clinical scoring system with the outcome of allergological assessment would allow the use of this tool in post-resuscitation and subsequent management of suspected perioperative immediate hypersensitivity reaction and potentially as a new standard reference for clinical investigations.

Methods: We prospectively scored 301 cases of suspected perioperative immediate hypersensitivity reaction according to the Hypersensitivity Clinical Scoring Scheme.

Effect of a Low-Dose/High-Frequency Training in Introducing a Nurse-Led Neonatal Advanced Life Support Service in a Referral Hospital in Ethiopia.

In Ethiopia, birth asphyxia causes ~30% of all neonatal deaths and 11-31% of deaths among neonates delivered in healthcare facilities that have breathing difficulty at birth. This study aimed to examine the impact of low-dose, high-frequency (LDHF) training for introducing a nurse-led neonatal advanced life support (NALS) service in a tertiary care hospital in Ethiopia. Through a retrospective cohort study, a total of 12,001 neonates born post-implementation of the NALS service (between June 2017 and March 2019) were compared to 2,066 neonates born before its implementation (between June 2016 and September 2016).

Scottish rheumatology sonography course: five-year experience of delivering a mentorship-model rheumatology ultrasound training programme accredited by the consortium for the accreditation of sonographic education.

Background And Aims: Ultrasound training for rheumatology practice in the UK is variable. Currently, there is no agreed minimum standard for training in ultrasound applied to rheumatology patient management. We present our experiences of implementing a competency driven ultrasound training, focused on hands and feet.

Relationship of perioperative anaphylaxis to neuromuscular blocking agents, obesity, and pholcodine consumption: a case-control study.

Background: The observation that patients presenting for bariatric surgery had a high incidence of neuromuscular blocking agent (NMBA) anaphylaxis prompted this restricted case-control study to test the hypothesis that obesity is a risk factor for NMBA anaphylaxis, independent of differences in pholcodine consumption.

Methods: We compared 145 patients diagnosed with intraoperative NMBA anaphylaxis in Western Australia between 2012 and 2020 with 61 patients with cefazolin anaphylaxis with respect to BMI grade, history of pholcodine consumption, sex, age, comorbid disease, and NMBA type and dose. Confounding was assessed by stratification and binomial logistic regression.

Anaphylaxis to intravenous paracetamol containing povidone. A case report and narrative review of excipient allergy related to anaesthesia.

Investigation of intraoperative anaphylaxis includes the exclusion of potential trigger agents the individual was exposed to within a plausible interval preceding the reaction. Occasionally, none of these agents will test positive. In this situation it is important to consider that excipients may be responsible for anaphylaxis, that the dilutions prepared to test the medication may not contain an appropriate concentration of the excipient to induce a positive skin reaction, or if an alternative formulation of the medication is tested, it may not contain the culprit excipient.

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

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.

Suspected perioperative allergic reactions: nomenclature and terminology.

Standardising nomenclature facilitates diagnostic and therapeutic algorithms, improves comparisons of data in scientific research and reduces misunderstanding. Here, we propose a nomenclature for suspected perioperative allergic reactions.

Consensus clinical scoring for suspected perioperative immediate hypersensitivity reactions.

Background: Grading schemes for severity of suspected allergic reactions have been applied to the perioperative setting, but there is no scoring system that estimates the likelihood that the reaction is an immediate hypersensitivity reaction. Such a score would be useful in evaluating current and proposed tests for the diagnosis of suspected perioperative immediate hypersensitivity reactions and culprit agents.

Methods: We conducted a Delphi consensus process involving a panel of 25 international multidisciplinary experts in suspected perioperative allergy.

The use of drug provocation testing in the investigation of suspected immediate perioperative allergic reactions: current status.

Suspected perioperative allergic reactions are often severe. To avoid potentially life-threatening re-exposure to the culprit drug, establishing a firm diagnosis and identifying the culprit is crucial. Drug provocation tests are considered the gold standard in drug allergy investigation but have not been recommended in the investigation of perioperative allergy, mainly because of the pharmacological effects of drugs such as induction agents and neuromuscular blocking agents.

Molecular mechanisms and pathophysiology of perioperative hypersensitivity and anaphylaxis: a narrative review.

Perioperative hypersensitivity reactions (POH) constitute a clinical and diagnostic challenge, a consequence of heterogeneous clinical presentations, and multiple underlying pathomechanisms. POH do not necessarily involve an allergen-specific immune response with cross-linking of specific immunoglobulin E (sIgE) antibodies on mast cells and basophils. POH can also result from alternative specific and non-specific effector cell activation/degranulation such as complement-derived anaphylatoxins and off-target occupancy of mast cell, basophil, or both surface receptors.

Comparative epidemiology of suspected perioperative hypersensitivity reactions.

Suspected perioperative hypersensitivity reactions are rare but contribute significantly to the morbidity and mortality of surgical procedures. Recent publications have highlighted the differences between countries concerning the respective risk of different drugs, and changes in patterns of causal agents and the emergence of new allergens. This review summarises recent information on the epidemiology of perioperative hypersensitivity reactions, with specific consideration of differences between geographic areas for the most frequently involved offending agents.

Management of a surgical patient with a label of penicillin allergy: narrative review and consensus recommendations.

Unsubstantiated penicillin-allergy labels are common in surgical patients, and can lead to significant harm through avoidance of best first-line prophylaxis of surgical site infections and increased infection with resistant bacterial strains. Up to 98% of penicillin-allergy labels are incorrect when tested. Because of the scarcity of trained allergists in all healthcare systems, only a minority of surgical patients have the opportunity to undergo testing and de-labelling before surgery.

Comparison of Collapsibility of the Human Upper Airway During Anesthesia and During Sleep.

Background: The propensities for the upper airway to collapse during anesthesia and sleep are related, although much of our understanding of this relationship has been inferred from clinical observation and indirect measures such as the apnea-hypopnea index. The aim of this study was to use an identical, rigorous, direct measure of upper airway collapsibility (critical closing pressure of the upper airway) under both conditions to allow the magnitude of upper airway collapsibility in each state to be precisely compared.

Methods: Ten subjects (8 men and 2 women; mean ± SD: age, 40.

Epinephrine (adrenaline) preventing recovery from intraoperative anaphylactic shock complicated by systolic anterior motion of the mitral valve with left ventricular outflow tract obstruction on transoesophageal echocardiography.

We describe a case of severe left ventricular outflow tract obstruction (LVOTO) with severe mitral incompetence due to systolic anterior motion of the anterior mitral leaflet (SAM) that was recognised thanks to the immediate availability of transoesophageal echocardiography during the resuscitation of anaphylactic shock. The patient rapidly responded to cessation of the epinephrine (adrenaline) infusion and intravascular volume expansion with intravenous crystalloid. The absence of risk factors for developing SAM/LVOTO serve as a warning to clinicians to consider this diagnosis in all cases of epinephrine non-responsive anaphylactic shock.

Consequences of proceeding with surgery after resuscitation from intra-operative anaphylaxis.

Intra-operative acute hypersensitivity reactions require a decision to be made regarding whether to proceed with or abandon the planned surgical procedure once the patient has stabilised. Using retrospective case controls, we examined all cases (223) of proven acute hypersensitivity reactions from 2005 to 2014 in Western Australia, in which the syndrome was recognised by the treating clinician before or during surgery, to determine whether recovery outcomes were adversely affected by proceeding with the planned procedure. Surgery proceeded in 104 patients (47%) and was abandoned in 119 (53%).

Cefalotin as antimicrobial prophylaxis in patients with known intraoperative anaphylaxis to cefazolin.

Background: The most common trigger for intraoperative anaphylaxis in Western Australia for the period 2014-5 was an antibiotic used for surgical prophylaxis, cefazolin. In these patients who subsequently present for surgery, alternative cephalosporins are forbidden by current guidelines because of concerns regarding an increased risk of anaphylaxis. However, consideration of the structure-activity relationships relevant to anaphylaxis suggests that cefalotin is a safe alternative because of structural dissimilarities, although there are no pubished clinical data relevant to the perioperative setting.

The First Case Report of Anaphylaxis Caused by the Inclusion Complex of Rocuronium and Sugammadex.

A 50-year-old man developed a severe anaphylactic reaction shortly after the administration of sugammadex at the end of an uneventful laparoscopic appendectomy. Subsequent skin testing was negative to all agents to which the patient was exposed including sugammadex. Because of the temporal relationship to the administration of sugammadex, further skin testing was performed with premixed sugammadex and rocuronium that produced a markedly positive response.

Epidemiology of perioperative anaphylaxis.

Anaphylactic reactions may be either of immune (allergy, usually IgE-mediated, sometimes IgG-mediated) or non-immune origin. The incidence of anaphylactic reactions during anaesthesia varies between countries ranging from 1/1250 to 1/18,600 per procedure. In France, the estimated incidence of allergic reactions is 100.

Efficacy of sugammadex in rocuronium-induced or antibiotic-induced anaphylaxis. A case-control study.

We report 13 cases of presumed rocuronium-induced anaphylaxis in which sugammadex was administered with the intention of reversing the immunological reaction. Of these 13 cases, eight (62%) were later confirmed to be type-1 hypersensitivity reactions to rocuronium, three (23%) were triggered by an antibiotic and two (15%) were non-immunologically mediated. Response to treatment was scored by the treating anaesthetist, and compared with haemodynamic and inotrope measurements from the resuscitation and anaesthetic records.

Effects on upper airway collapsibility of presence of a pharyngeal catheter.

Catheters that traverse the pharynx are often in place during clinical or research evaluations of upper airway function. The purpose of this study was to determine whether the presence of such catheters affects measures of upper airway collapsibility itself. To do so, pharyngeal critical closing pressure (Pcrit) and resistance upstream of the site of collapse Rus) were assessed in 24 propofol-anaesthetized subjects (14 men) with and without a multi-sensor oesophageal catheter (external diameter 2.