Perioperative allergic reactions: experience in a Flemish referral centre

Abstract

Background: The incidence of perioperative anaphylactic reactions is overall estimated to be 1 per 10,000-20,000 anaesthetic procedures. We performed a retrospective analysis of patients referred to a University Allergy Centre in Belgium with the suspicion of an allergic reaction during or shortly after general anaesthesia.

Objectives: Our aim was to assess the causes of perioperative allergic reactions, to evaluate cross-reactivity among neuromuscular blocking agents (NMBA) and to analyze the diagnostic relevance of tryptase levels in the discrimination between IgE and non-IgE-mediated reactions.

Methods: A total of 119 patients, referred from 2007 to 2011 were included. The diagnostic protocol consisted in case history, serum tryptase measurements, immunoassays and skin tests.

Results: A diagnosis of IgE-mediated reaction was established in 76 cases (63.9%). The most common agents were NMBA (61.8%), antibiotics (14.5%), latex (9.2%) and chlorhexidine (5.2%). Rocuronium was the most frequently causative NMBA (48.9%). Vecuronium cross-reactivity was established by skin testing in 47.6% of cases. Cisatracurium was the NMBA most frequently tolerated (cross-reaction in 13.9%). In 23.4% of NMBA allergic patients, the reaction occurred on the first exposure. Most IgE-mediated reactions occurred during the induction phase (72.4%). Latex-induced reactions occurred mainly during maintenance and recovery phases (71.4%; p<0.02). Mean tryptase values were significantly higher in patients with IgE-mediated reactions (p=0.0001), than in those with no identified cause.

Conclusions: NMBA, antibiotics, latex and chlorhexidine were the main culprits of IgE-mediated perioperative reactions. Uncertainties remain concerning the specificity and sensitivity of skin testing. Tryptase assays can be useful in the discrimination of IgE and non-IgE-mediated reactions.

Keywords: Anaesthesia; Drug allergy; Latex; Neuromuscular blocking agents; Tryptase.