New Guidelines for Managing Anaphylactic Reactions During Surgery

Anesthetists in the UK and Ireland have been issued with new guidelines on how to prevent and handle emergencies involving the small, but growing, number of people who have a severe and potentially fatal allergic reaction during anesthesia.

The new guidelines, devised by a working group of the Association of Anesthetists of Great Britain and Ireland (AAGBI; London, United Kingdom), cover initial management and drug advice, secondary management, investigation, and later investigations to discover what caused the reaction. The guidelines are based on a research review carried out by the AAGBI working group, which found that reactions to neuromuscular blocking agents and the latex gloves worn by surgical staff are more common in female patients; antibiotic anaphylaxis is more common in smokers, possibly because of increased exposure to repeated courses of antibiotics for respiratory tract infections; patients with a history of allergic skin diseases, asthma, and food allergies appear to face a greater risk from latex, but not from neuromuscular drugs or antibiotics; individuals who have asthma or take beta-blocking drugs may suffer a more severe reaction; and people who suffer allergies to common environmental chemicals in toothpastes, washing detergents, shampoos and cough medicine may be more sensitive to neuromuscular blocking agents.

On the other hand, the group found that reactions to local anesthetics are very uncommon, prompting them to suggest that having operations under local anesthesia rather than general anesthesia may reduce the risk of some patients having an allergy-related reaction. This is supported by the fact that approximately 60% of adverse reactions are associated with muscle relaxant drugs, which are only administered when a patient is under a general anesthetic. The detailed guidelines are available on the AAGBI website, and are being supported by an A4 print laminate format, designed to be kept in operating theatres so it can be readily available in an emergency.

"All anesthetists are trained to deal with anaphylaxis, which can trigger dangerously low blood pressure and may cause severe breathing problems, but most anesthetists will only see a small number of cases during their career,” said Nigel Harper, M.D., chair of the AAGBI workgroup. "That is why it is so important to keep them up-to-date with the latest information on diagnosis and treatment and provide emergency guidance for use in operating theatres.”

Studies from France and Australia indicate that the incidence of life-threatening anaphylaxis during anesthesia is between one in 10,000 to 20,000 patients. This suggests that there could be approximately 500 severe reactions in the UK each year, and that they are more common when drugs are administered intravenously. However, when the working party looked at the actual UK figures, they found that only 361 reactions had been reported over six years, and that 10% of these were fatal. This compared with 789 incidents in France over a two-year period, which has a comparable population and a well-established culture of reporting anesthesia-related reactions. This led the workgroup to speculate that it is likely that less-severe reactions are not reported in the UK and the true number could be much higher.

Related Links:
Association of Anaesthetists of Great Britain and Ireland