British allergy society issues guidelines for investigating anesthesia-related anaphylaxis

The Standards of Care Committee of the British Society for Allergy and Clinical Immunology (BSACI) has published guidelines and algorithms for the systematic investigation of anaphylaxis that occurs during general anesthesia. Identifying the allergen is equally as important as identifying the safe alternatives for the patient. Ewan et al. (Clin Exp Allergy 2010 Jan;40(1):15-31.) pressed the importance of these recommendations for accumulating data on anesthetic drugs because there is no supporting data for most drugs used in general anesthesia and it is impossible to do graded challenges with many anesthetic drugs. Additionally, they recommended that the investigation be conducted at a dedicated drug allergy center, to capitalize on the expertise and volume managed at these centers.

The guidelines begin with the obligations of the anesthetist and the allergist, with the anesthetist being responsible for initiating the investigation. Anesthetist responsibilities start post-resuscitation with serum tryptase levels immediately, 1-2 hours, and >24 hours after recovery. They also inform the patient and refer them to the drug allergist. The allergist then follows up with patients and medical documentation to begin the process of identifying most likely causes of anaphylaxis [and distinguishing them from other complications of general anesthesia] and initiating skin prick testing, intradermal testing, and/or challenge. Detailed recommendations for and reliability of technical aspects of the investigation, such as skin prick and cross-reactivity testing, are also covered by Ewan et al.

The authors noted that the most common reaction was to neuromuscular blocking agents [NMBA], though there is an increase in anaphylaxis cases to latex and antibiotics administered peri-anesthetically. They reported that allergic reactions to local anesthetics are extremely rare and that there are no reports of reaction to inhaled anesthesia.

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