Anaphylaxis in the perioperative environment is a rare occurrence, however it requires immediate recognition and treatment. Anaphylaxis is a life-threatening emergency in response to a trigger factor, usually with symptoms developing quickly after exposure to the triggers such as food, medications or insect venom. Within the perioperative environment, anaphylaxis is most commonly associated with the administration of medications. As most medications are administered intravenously, the onset of symptoms is often rapid and needs to be managed to prevent further clinical deterioration. Frequent triggers within the perioperative environment included antibiotics, neuromuscular blocking agents and chlorhexidine.
Grading of anaphylaxis severity is as follows:
Adapted from Worm et al (2014) https://doi.org/10.3238/arztebl.2014.0367 modification of Ring and Messmer 1977
For patients who have Grade III (severe) anaphylaxis, the cutaneous signs are often absent as perfusion to the skin is inadequate to produce symptoms. Additionally, central nervous symptoms of lightheadedness, confusion and a sense of impending doom are associated with hypotension and poor perfusion to the brain. In the perioperative settings, conditions such as anaesthesia and draping may obscure early signs of anaphylaxis as the patient is unable to report symptoms, and drapes may obscure visualisation of skin changes.
Once anaphylaxis has been identified, immediate treatment is required to stop the allergic cascade from producing histamines, prostaglandins and cytokines, and manage the effects of these agents. Management will include immediate treatment, refractory management and post crisis management. The Australian and New Zealand College of Anaesthetists (ANZCA) and Australian and New Zealand Anaesthetic Allergy Group (ANZAAG) have worked together to produce Anaphylaxis cognitive aids for these stages of management in both adult and paediatric patients. Each of these cards should be printed and laminated for easy access during anaphylaxis, preferably located in/next to the anaphylaxis emergency box.
Treatment of anaphylaxis:
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Article reviewed August 2023 by Susie Helmrich.
Australian and New Zealand College of Anaesthetists (ANZCA) and Australian and New Zealand Anaesthetic Allergy Group (ANZAAG). 2016. Perioperative Anaphylaxis Management Guidelines.
Australian and New Zealand College of Anaesthetists (ANZCA) and Australian and New Zealand Anaesthetic Allergy Group (ANZAAG). 2016. Perioperative Anaphylaxis Management Guidelines Background Paper.
Australian and New Zealand College of Anaesthetists (ANZCA) and Australian and New Zealand Anaesthetic Allergy Group (ANZAAG). 2016. Adult Immediate Management Card.
Australian and New Zealand College of Anaesthetists (ANZCA) and Australian and New Zealand Anaesthetic Allergy Group (ANZAAG). 2016. Paediatric Immediate Management Card.
Australian and New Zealand College of Anaesthetists (ANZCA) and Australian and New Zealand Anaesthetic Allergy Group (ANZAAG). 2016. Adult Refractory Management Card.
Australian and New Zealand College of Anaesthetists (ANZCA) and Australian and New Zealand Anaesthetic Allergy Group (ANZAAG). 2016. Paediatric Refractory Management Card.
Australian and New Zealand College of Anaesthetists (ANZCA) and Australian and New Zealand Anaesthetic Allergy Group (ANZAAG). 2016. Differential Diagnosis Card.
Australian and New Zealand College of Anaesthetists (ANZCA) and Australian and New Zealand Anaesthetic Allergy Group (ANZAAG). 2016. Post Crisis Management Card.
Crystal Smith is a Senior Education Consultant for Critical Care Education Services (part of the Medcast Group). She has a clinical background in critical care, paediatrics and education.
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