Mod12: Anaphylactic vs Anaphylactoid Reactions - What causes reaction? Flashcards
Anaphylactic vs Anaphylactoid Reactions
Based on 5,644 cases of anaphylaxis during anesthesia over 25 years (1980-2004), what’s the most common cause of an allergic reaction during anesthesia?
Muscle relaxants 3,509 (62%)
<strong>Latex</strong> 955 (17%)
<strong>Antibiotics </strong> 365 (6.4%)
Hypnotics 349 (6.1%)
Colloids 194 (3.4%)
Opioids 112 (1.9%)
Others 160 (2.8%)
Anaphylactic vs Anaphylactoid Reactions
What are causes of allergic reactions that are not unique to anesthesia?
Latex 955 (17%)
Antibiotics 365 (6.4%)
Anaphylactic vs Anaphylactoid Reactions
From NMBA – 3,509 cases, which muscle relaxants are the most a/w allergic reactions?
Succinylcholine 1,437 (41%)
Rocuronium 905 (25%)
Atracurium 475 (13%)
Vecuronium 387 (11%)
Pancuronium 251 ( 7%)
Mivacurium 40 ( 1%)
Cisatracurium 11 (0.3%)
Others 3 (0.08%)
Anaphylactic vs Anaphylactoid Reactions
Why do we see a higher incidence of hypersensitivity reaction right at induction?
Because that’s when we administer large quantities of muscle relaxants
Remember that anaphylactoid will be dose dependent
Anaphylactic reaction will not
Anaphylactic vs Anaphylactoid Reactions
From a French Study of 789 anaphylactic and anaphylactoid reactions, what were the leading causes of these reactions during anesthesia?
NMB 58%
Latex 17%
Antibiotics 15%
Anaphylactic vs Anaphylactoid Reactions
True or False: NMBA can produce dose-dependent, nonimmunologic histamine release related to the rate of administration
True
Anaphylactic vs Anaphylactoid Reactions
Which specific structure in muscle relaxants is responsible for allergic reaction
Quaternary ammonium ion

Anaphylactic vs Anaphylactoid Reactions - NMBA
In what percentage of cases is cross sensitivity with one or more muscle relaxants seen?
63% of cases
Anaphylactic vs Anaphylactoid Reactions - NMBA
True or False: Muscle relaxants cross-react with compounds containing quaternary and tertiary ammonium ions
True
Anaphylactic vs Anaphylactoid Reactions - NMBA
Muscle relaxants cross-react with compounds containing quaternary and tertiary ammonium ions. Which substances contain these ions?
Many drugs - Foods - Cosmetics
Disinfectants - Industrial materials
Νeostigmine and morphine
Anaphylactic vs Anaphylactoid Reactions
Which anesthetic drugs will you be hesitant to administer to a pt with a known anaphylactic reaction to Neostigmine or Morphine?

NMBAs
Anaphylactic vs Anaphylactoid Reactions - NMBA
Why do 90% to 95% of anaphylactic reactions to muscle relaxants occur in women?
Exposure to ammonium ion epitopes in cosmetics may elicit sensitization
Patients may become sensitized through environmental contact with these substances
Anaphylactic vs Anaphylactoid Reactions - Latex Hypersensitivity
Which three groups are at higher risk to of Latex Hypersensitivity and reaction
Health care workers
Children with spina bifida and genitourinary abnormalities
Workers with occupational exposure to latex
Anaphylactic vs Anaphylactoid Reactions - Latex Hypersensitivity
True or False: The more you are exposed to latex, the more your risk of being hypersensitive to it goes up
True
Anaphylactic vs Anaphylactoid Reactions - Latex Hypersensitivity
True or False: Latex Hypersensitivity should be considered as a possible cause of any reaction that occurs during anesthesia
True
Anaphylactic vs Anaphylactoid Reactions - Latex Hypersensitivity
When during anesthesia do most cases of latex-induced anaphylaxis occur?
about 30 minutes after induction
Anaphylactic vs Anaphylactoid Reactions - Latex Hypersensitivity
Which food items may contain cross-reacting allergens that could cause latex hypersensitivity?
Mango - Banana - Avocado
Kiwi - Passion fruit - Chestnuts
Anaphylactic vs Anaphylactoid Reactions
Which potential hypersensitivity reaction would you consider in a patient with allergies to these food items: Mango, Banana, Avocado, Kiwi, Passion fruit, Chestnuts?
Latex Hypersensitivity
Anaphylactic vs Anaphylactoid Reactions - Latex Hypersensitivity
Patients who have systemic reactions to latex during anesthesia often have a prior history of contact urticaria or angioedema from which other synthetic items?
Rubber gloves - Balloons - Condoms
Anaphylactic vs Anaphylactoid Reactions - Latex Hypersensitivity
Why would you ask someone who reports a latex allergy if they use special underwear?
Most underwear have some form of latex in the banding
Someone with a true anaphylactic reaction to latex will tell you they cannot wear standard underwear
They will have to purchase special underwear with zero latex
If they wear normal underwear and never had any issues, they may have hypersensitivity, but not anaphylaxis to latex
Anaphylactic vs Anaphylactoid Reactions - Latex Hypersensitivity
True or False: you should remove rubber stoppers from drug vials in potential hypersensitivity or anaphylaxis to latex
True
(Not completely necessary according to some litterature)
Anaphylactic vs Anaphylactoid Reactions
Under anesthesia, which is the most frequent cause of anaphylaxis among antibiotics?
Penicillin
Estimated to be responsible for 75% of anaphylactic deaths in the United States
Anaphylactic vs Anaphylactoid Reactions
True or False: over 80% of patients with a history of allergy to penicillin have penicillin specific IgE antibodies as detected by skin testing
False
Over 80% of patients with a history of allergy to penicillin do not have penicillin specific IgE antibodies as detected by skin testing
Anaphylactic vs Anaphylactoid Reactions
What’s the similarity between Cephalosporins and Penicillin’s which accounts for varying degrees of cross-reactivity between the two?
Common beta-lactam ring structure
Anaphylactic vs Anaphylactoid Reactions
According to recent litterature, what’s the probability of the risk of allergic reactions to cephalosporins in patients allergic to penicillin?
Less than 10%
Anaphylactic vs Anaphylactoid Reactions
Which generation of cephalosporins poses a greater risk of cross-reactivity with Penicillins
First generation cephalosporins (Ancef)
pose a greater risk than second or third generation cephalosporins
(Ceftin, Zinacef, Cefotaxime, Rocephin)
Anaphylactic vs Anaphylactoid Reactions
What could you do to test if a cephalosporin drug has cross-reactivity with Penicillin?
Give 10% of the dose IV to see if they have a reaction
Do a little skin wheel and leave for 5 minutes and look for a reaction
Should see redness erythema develop w/in 1st 5 min
If not, ok to administer test dose, followed with full dose
Anaphylactic vs Anaphylactoid Reactions
True or False: incidence of allergic reactions with colloids seems to be increasing
True
Anaphylactic vs Anaphylactoid Reactions
Of the synthetic colloids, which one is more likely to cause a reaction?
Dextran
(about the same or a little less than albumin)
Anaphylactic vs Anaphylactoid Reactions
What’s the % risk of allergic reaction for both Dextran and Albumin?
They are both around 0.5 - 1% risk of causing an allergic reaction
Anaphylactic vs Anaphylactoid Reactions
True or False: reactions from colloids are more common in males than females
True
Anaphylactic vs Anaphylactoid Reactions
True or False: Egg allergy is a contraindication to use of albumin
False
Egg allergy is not a contraindication to use of albumin (different protein)
Anaphylactic vs Anaphylactoid Reactions
What causes Reactions to opioids?
Direct mast cell mediator release
(Mimic IgE-dependent mechanisms, but is actually from the histamine release)
Anaphylactic vs Anaphylactoid Reactions
Which opioid produces greatest histamine release?
Demerol
Morphine also has a significant histamine release
Anaphylactic vs Anaphylactoid Reactions
Most opioid-induced reactions are not life threatening; which symptoms are they associated with?
Mild hypotension (most common)
Hives - Pruritus
Anaphylactic vs Anaphylactoid Reactions
Which drugs could be used to treat symptoms associated with opioid-induced reactions?
Benadryl
Steroids
Anaphylactic vs Anaphylactoid Reactions
Which opioids should you avoid if you are concerned about hypotension?
Demerol
Morphine
Anaphylactic vs Anaphylactoid Reactions
Which type of hypersensitivity reaction is associated with Aspirin and NSAIDs?
Non-IgE-mediated adverse effects
Anaphylactic vs Anaphylactoid Reactions
Which systemic effects result from ASA and NSAIDs that resemble allergic reactions
Bronchospasm
Urticaria
Angioedema
Laryngeal edema
Anaphylactic vs Anaphylactoid Reactions
True of False: there is a test to identify patients who are intolerant to ASA or NSAIDs
False
No definitive skin or in vitro test to identify patients who are intolerant to ASA or NSAIDs exist
Anaphylactic vs Anaphylactoid Reactions
True or False: only nonimmune mechanisms have been reported with Protamine
False
Both nonimmune and immune (IgE) mechanisms have been reported with Protamine
Anaphylactic vs Anaphylactoid Reactions
Which patients are more likely to have a life-threatening adverse reaction to intravenous protamine?
Diabetics who have had treatment with protamine-containing insulin
They are 40 to 50 times more likely to have a life-threatening adverse reaction to intravenous protamine
Men that have had vasectomies
(Probably because Protamine was originally made from salmon sperms)
Anaphylactic vs Anaphylactoid Reactions
IgE-mediated systemic anaphylaxis is rare with local anesthetics. Which compounds are linked to local anesthetics related anaphylactic reactions when they occur?
Para-amino-benzoic acid metabolite from esters, or
The preservative Methylparaben
Anaphylactic vs Anaphylactoid Reactions - Local anesthetics
In patients who have had reactions to an ester-type local anesthetic, which LA should be considered for dose testing?
an Amide LA
(and vice versa)
Anaphylactic vs Anaphylactoid Reactions - Local anesthetics
If the patient had a reaction to an amide, which LA may be used? why?
another Amide may be used
because the cross reactivity among amides is rare
Anaphylactic vs Anaphylactoid Reactions - Local anesthetics
True or False: Cross reactivity among amides is rare
True
Anaphylactic vs Anaphylactoid Reactions
What’s Methyl-meth-acrylate?
Glue used in orthopedic surgery
(Bone cement??)
Anaphylactic vs Anaphylactoid Reactions - Methylmethacrylate
Which effects are associated with an allergic reaction to Methyl-meth-acrylate?
Hypotension - Hypoxemia
Noncardiogenic pulmonary edema
Cardiac arrest
Anaphylactic vs Anaphylactoid Reactions - Methylmethacrylate
What is Methyl-meth-acrylate allergic mechanism?
No known
Anaphylactic vs Anaphylactoid Reactions - Radiocontrast materials (RCM)
True or False: anaphylactoid reactions from Radiocontrast materials (RCM) are clinically indistinguishable from IgE-mediated anaphylaxis
True
Anaphylactic vs Anaphylactoid Reactions - Radiocontrast materials (RCM)
Why is it important to ask the pt when they had a reaction to RCM?
Most reactions a/w older RCM from the 70s
Newer RCMs are not a/w with the same level of reactions
They may be safe taking newer RCM
Monitor carefully