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

Abstract

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. Classification of cases was by allergological workup based on immediate and delayed investigations. The discrimination and calibration of the Hypersensitivity Clinical Scoring Scheme was compared with results from an expert panel of allergologists, skin testing, mast cell tryptase ratios, and specific IgE assays, as was agreement by Cohen's kappa coefficient.

Results: The Hypersensitivity Clinical Scoring Scheme predicted cases of allergic perioperative immediate hypersensitivity reaction with comparable discrimination to an expert panel, mast cell tryptase formula, and specific IgE assays in anaphylaxis to neuromuscular blocking drugs. Using a score threshold of 15 or greater to indicate allergic perioperative immediate hypersensitivity reaction, the sensitivity was 88.9%, with a specificity of 79.4%. Prospectively, the Hypersensitivity Clinical Scoring Scheme correctly classified a greater number of subjects than the expert panel and the optimal post hoc binary logistic regression model (86% vs 85% vs 84%), however it was inferior to skin testing.

Conclusion: The Hypersensitivity Clinical Scoring Scheme predicts allergic perioperative immediate hypersensitivity using features of the acute syndrome. This approach could guide algorithms for the post-resuscitative management of suspected perioperative immediate hypersensitivity, and identify patients requiring drug provocation challenge.

Keywords: allergy; anaphylaxis; immediate hypersensitivity; perioperative; scoring system.