Anaphylaxis : Colligative - Practical Wisdom in Anesthesia, Surgery, and Medicine.

Jan 19, 2013

Any acute onset of hypotension or bronchospasm or upper airway obstruction where anaphylaxis is considered possible, even if typical skin features are not present.

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Jan 19, 2013

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Definition

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Risk factors

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Reducing Risk

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1

Recognition

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Presenting clinical features and percentage frequency are:
Cardiovascular collapse 88%,
Erythema 45%,
Bronchospasm 36%,
Angio-oedema 24%,
Rash 13%, and
Urticaria 8.5%.
refl.in/7u

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May 04, 2012

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Immediate management

1. Switch to 100% oxygen
2. Summon for assistance and inform the surgeon
3. Intramuscular (IM) or intravenous (IV) adrenaline
4. Start rapid intravascular volume expansion with Hartmann’s or saline solution plus elevate the legs. www.frca.co.uk/article.as...
5. Once adrenaline has been administered and rapid intravenous fluid infusion commenced, external chest compression may be required if there is no cardiac ouput to facilitate venous return to the heart. www.frca.co.uk/article.as...

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Oct 12, 2012

Adrenaline's effect in anaphylaxis is due to actions at multiple sites. Its alpha-1agonist activity reverses the peripheral vasodilation caused by inflammatory mediator release and reduces oedema. Its beta-receptor activity relaxes bronchial smooth muscle, increases myocardial contractility, suppresses histamine and leukotriene release, and reduces the severity of IgE-mediated allergic reactions. refl.in/7t

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Oct 23, 2011

If bronchospasm is noted, consider the potential for gas trapping and high alveolar pressures leading to elevated intrathoracic pressure/pulmonary vascular resistance and reduced cardiac output.
Consider prolonging the expiratory time and/or disconnecting the ETT for 10 seconds to allow for relief of pressure.

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(1 comment)

Oct 12, 2012

See www.anaesthesiacases.com.... for a relevant case

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Intramuscular route for adrenaline is an effective alternative to the intravenous route

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Oct 11, 2011

Adult: 500mcg IM, Child 6-12yrs 300mcg IM, Child <6yrs 150mcg IM. refl.in/7t

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Is said to work almost as quickly as intravenous route #ref

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Intravenous adrenaline titrated to effect

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Jan 19, 2013

Adult 50mcg IV, Child <12yrs 1mcg/kg IV. refl.in/7t

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Ongoing management

Allergy testing to be performed more than six weeks after event to allow for normalisation of the immunological response after the event.

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Oct 17, 2011

Assess for supgraglottic airway oedema once symptoms resolved with nasendoscopy, but have low threshold for transfer to ICU intubated.

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Jun 10, 2011

Catecholamine infusions for persistent CVS instability. Adrenaline/epinephrine or Noradrenaline/norepinephrine.

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Jun 10, 2011

Dose range 0.1-0.5 mcg/kg/min. refl.in/7u

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Collect blood for serum tryptase measurement at 1-2hrs and again between 6-24 hrs to help confirm the diagnosis of anaphylaxis if unsure. refl.in/kj

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Jan 20, 2012

Discuss risk/benefit of continuing with surgery with surgeon. Consider waiting for a period of stability in theater before decision is made.

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Jun 10, 2011

Disposition to ICU if laryngeal oedema, persistent bronchospasm, hypoxia, pulmonary oedema,
ongoing CVS instability, dependence on inotropes, or severe metabolic acidosis. refl.in/7u

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Oct 11, 2011

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Documentation, Handover

Submit the case to the Victorian Consultative Council on Anesthetic Mortality and Morbidity (VCCAMM) #victoria refl.in/ki

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Oct 07, 2011

Write a letter to the patient and their family/general practitioner describing details of the event and ongoing plans.

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Oct 17, 2011

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Guidelines, Protocols

Australian prescriber wallchart 2011. Anaphylaxis: Emergency management for health professionals. From refl.in/ni

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Mar 12, 2012

Australian Society of Clinical Immunology and Allergy - Health Professional Information Paper ASCIA anaphylaxis

Good summary

www.allergy.org.au/images...

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Jan 18, 2013

Management of anaphylaxis in the community or emergency department. Australian prescriber 2007. refl.in/n8

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Feb 13, 2012