Allergy & Anaphylaxis

Transcription

1 Allergy & Anaphylaxis (why, where, and what to do) Robert H. Brown, M.D., M.P.H. Professor Departments of Anesthesiology, Environmental Health Sciences, Medicine, and Radiology The Johns Hopkins Medical Institutions Baltimore, Maryland

2 Goals and Objectives 1) Recognize the clinical presentation of anaphylactic reactions. 2) Summarize the management of an anaphylactic reaction. 3) List the common agents responsible for anaphylactic reactions. 4) Describe desensitization therapies to reduce the incidence of anaphylactic reactions.

3 Publications 1000 Anaphylaxis Anaphylaxis Number of Publications year (

4 250 Publications pediatric anaphylaxis Number of Publications year (

5 Overview of the Allergic Cascade B lymphocyte Release of Allergic mediators ε-switch Plasma cell Release of IgE Allergens Anaphylaxis Mast cells Basophils

6 IgE-dependent Release of Inflammatory Mediators IgE Allergens Immediate Release Granule contents: Histamine, TNF-α, Proteases, Heparin, Tryptase Over Minutes Lipid mediators: Prostaglandins Leukotrienes Over Hours Cytokine production: Specifically IL- 4, IL-13

7 Signs and Symptoms Skin: hives, erythema, urticaria, pruritis, localized or general Eyes: red, itching, angioedema Upper respiratory: stuffy or runny nose Lower respiratory: shortness of breath, cough, wheezing GI: cramps, nausea, vomiting, diarrhea CV: hypotension, tachycardia, cardiovascular collapse

8 Intraoperative Symptoms (Anesth Analg 2011;113: )

9 Immediate Treatment Stop exposure (determine causative agent) Airway management, intubate if necessary Volume expansion with balanced salt solution Epinephrine, starting dose µg/kg, titrate as needed Bronchodilators (if needed) See (Dewachter et al. Anesthesiology 103:40, 2005)

10 This reluctance to administer epinephrine is even reflected in our study of the treatment of anaphylaxis during anesthesia, where anesthetists chose to administer antihistamines and steroids before epinephrine in 16.8% of patients and did not administer epinephrine at all in 17.2% of patients having C3 and C4 reactions with cardiovascular instability. Reasons for this are unclear, but could be because of limited knowledge of the treatment algorithm for anaphylaxis, lack of experience with the use of epinephrine outside the cardiac arrest setting, or a reluctance to treat a tachycardic patient with a drug with a positive chronotropic effect. Because there is no proven benefit of antihistamines and steroids in anaphylactic shock the administration of epinephrine should always precede treatment with antihistamines and steroids once the diagnosis of anaphylaxis has been made. Anesthesiology 2011; 115:111 6

11 Differential Diagnosis (Liccardi et al. J Investig Allergol Clin Immunol. 18: 1, 2008)

12 Postoperative Care Check that environment is safe Transfer to monitored area

13 Diagnosis History: timing of events, previous reactions. Nonspecific markers in the blood: Serum tryptase: peak ~1 hr (t 1/2 2 hrs) (red top, collect within 4 hrs) Serology: IgE specific antibodies (if available) Skin Test: (when available, with caveats) (Gomez et al. Allergol Immunopathol (Madr). 43:203, 2015) (Guyer et al. J allergy Clin Immunol 3:94, 2016) (Kuhlen et al, J Allergy Clin Immunol Pract. 4: 697, 2016)

14 Diagnosis N=111 referred to clinic for suspected allergic reaction while under anesthesia N=5 suggestive agent confirmed N=67 suggestion of a causative agent N=13 partial match (add n causative agents) N=49 suggestive agent not confirmed N=44 no suggestion of a causative agent N=31 no agent confirmed N=18 other agent confirmed (Krøigaard et al., Brit J Anaesth. 95: 468, 2005)

15 Causative agents (General) Pediatric Emergency Care. 29(2): , 2013.

16 Causative agents (Perioperative) (USA, Mayo, n=38 adults) Agents Antibiotics Latex Induction agents Neuromuscular Agents Opioids Other agents No. events (%) 9 (50.0%) 3 (16.7%) 3 (16.7%) 2 (11.1%) 1 (%) 4 (%) (Gurriari, Anes Analg 113: 1202, 2011)

17 Causative agents (Perioperative) (USA, Cleveland Clinic, n=30 adults) Agents Antibiotics Neuromuscular Agents Latex No agent identified No. events (%) 10 (33%) 4 (13%) 3 (10%) 13 (43%) (Gonzalez-Estrada et al., J Allergy Clin Immunol Pract. 3: 101, 2015)

18 Causative agents (Perioperative) (USA, MGH, n=25 adults; only 9 ST+) Agents Antibiotics Latex Induction agents Neuromuscular Agents Opioids Other agents No. events (%) (Kuhlen et al, J Allergy Clin Immunol Pract. 4: 697, 2016)

19 Causative agents (Intraoperative) (Singapore, n=34 adults) Total rank (Chenet al., Singapore Med J. 57: 126, 2016)

20 Causative agents (Perioperative) (France, n=477 adults) Agents Neuromuscular Agents Latex Antibiotics Hypnotics Opioids Colloids Other agents No. events (%) 336 (69.2%) 59 (12.1%) 39 (8.0%) 18 (3.7%) 7 (1.4%) 13 (2.7%) 14 (2.9%) (Laxenaire, Br J Anaesth 87: 549, 2001)

21 Causative agents (Perioperative) (Norway, n=83 adults) (Harboe et al., Anesthesiol. 102: 897, 2005)

22 Causative agents (Perioperative) (France, n=68 children) Allergy 2005: 60:

23 (Harboe et al. Allergy, 62:1445, 2007)

24 Cross Reactivity among allergic reactions to NMBA Anaesth Intensive Care 2012; 40:

25 Publications Natural rubber latex allergies (

26 Goal Make Johns Hopkins Hospital a latex safe institution. (Brown et al. Joint Commission Journal on Quality and Safety 29: , 2003) (Brown et al. Joint Commission Journal on Quality and Safety 35: , 2009) Definitions At Risk - Any individual with identified risk factors who, if exposed to a significant amount of latex allergen, are likely to develop a latex allergy. Latex Safe Environment - An area with minimal latex allergen, insufficient to elicit a latex allergic reaction. Latex Free Environment - An area with no latex allergen. (A handful of products are still used at JHH that contain latex)

27 Wikipedia Latex allergy

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29 Potential New Approaches to the Treatment of (Food) Allergy Anti-IgE antibodies (Xolair) Immunotherapy intact allergen modified allergens homologous proteins plasmid vaccines Ingestion of extensively heated milk and egg From Robert A. Wood, MD Professor of Pediatrics and International Health; Director, Pediatric Allergy and Immunology, JHMI

30 Summary of Immunotherapy Study Results In small studies of children with significant milk, peanut, and egg allergy, oral immunotherapy is capable of inducing significant changes in threshold for clinical reactivity Tolerance is only accomplished in a minority of patients Rates of adverse reactions (~30%, GI, skin, respiratory, multisystem) are significant but likely acceptable, especially if most develop long term tolerance Further study is clearly warranted to decrease adverse reactions and improve efficacy, including more consistent induction of long term tolerance

31 Acknowledgement Robert Hamilton, Ph.D. James Schauble, M.D. Kathy Hale, R.N. Steven Kleeberger, Ph.D. Margaret Mintz, B.A. Anne Jedlicka, B.S. Mary McAllister, M.A. Alan Scott, Ph.D. Timothy Buckley, Ph.D. Kannika Taenkhum, M.H.S. Connie Monitto, M.D. Colleen Cusick Linda Bushell-English Betty Gibula William Kennett Johns Hopkins Hospital Latex Task Force Associations of School of Public Health/CDC S1208