LOOK FOR
Cardiovascular changes (1)
Hypotension, circulatory collapse
Tachy - OR bradycardia (2)
Respiratory changes
Bronchospasm (3)
Pulmonary oedema
Erythema/Skin Rash/Pruritus (4)
Oedema of the face and lips
Nausea and vomiting in awake patients (5)
LOOK FOR (6)
Allergic reaction to drugs, colloids, blood products, latex
EMERGENCY MANAGEMENT
Complete COVER ABCD - A SWIFT CHECK
Do not hesitate to treat as cardiac arrest
Inform the surgeon
Request immediate assistance
Cease all drugs/plasma expanders/blood products
Immediate and aggressive volume expansion (7)
Maintain ventilation with 100% oxygen
Give adrenaline bolus. Adults: 0.5 mg IV (as
1;10,000 dilution) slowly (over 10 minutes with monitoring). If
necessary follow with an infusion
of 1mg in 100 ml burette. Start at 60 ml/hr.
(see also adrenaline dosage
calculations).
Children: 10
mcg/kg IV (as 1;10,000 dilution) slowly (over 10 minutes with monitoring). If
necessary follow with an infusion
0.1 - 1.0 mcg/kg/minute.
Titrate carefully against heart rate, blood pressure and clinical response of
the allergy - see also
(8)
FURTHER CARE
The patient may relapse
Continue the adrenaline infusion for days, if necessary
Consider other drugs (9)
Admit to HDU/ICU
Take bloods for testing as soon as possible (10)
Counsel the patient/relatives
See - After the Crisis
Provide written advice
and document this in the medical record
Arrange for allergy testing at 1 month
NOTES:
 Top
The earliest signs of anaphylaxis are hypotension, bronchospasm and skin signs.
At least one of these manifested in 51% of cases. 65% of
patients were ASA grades 1-2. The figures reported here are based on an analysis
of 148 reports of allergy (76 of them severe) in the first 4000 AIMS anaesthesia
incidents.
It was judged that the correct use of the algorithm would have led to
earlier recognition of the problem and/or better management in 30% of the 122
relevant incidents reported to AIMS.
(1) Over
half of all reactions were judged as severe, and 89% of these involved
circulatory collapse.
There was hypotension in 68% of all cases.
(2) Heart rate changes were documented in 28% of reports, being equally split
between tachy- and brady- cardias.
Bradycardia invariably heralded circulatory
collapse.
(3) Bronchospasm was documented in 42% of cases.
(4) Erythema/urticaria/rash was documented in 48% of cases. Facial/airway oedema
was an uncommon sign
(5) Nausea and vomiting occurred in 45% of awake patients.
(6) 35% of cases involved polydrug therapy at induction. Drugs or agents
commonly implicated were:
-Cephalosporins - 24%
-Haemaccel - 9%
-Non-depolarising relaxants - 8%
-Penicillin - 5%
-Thiopentone - 5%
-Blood products - 2%
Other drugs implicated include: suxamethonium, propofol, protamine, amide-type
local anaesthetics.
(7) Immediate crystalloid bolus of 10 ml/kg IV. Review and repeat as necessary.
Haemaccel and blood products should be avoided. Elevation of the legs may be
helpful if possible.
(8) Intravenous adrenaline (epinephrine): In severely ill patients
when there is doubt about adequacy of absorption from intramuscular injection
sites, give adrenaline by slow IV injection, stopping when a response is
obtained. Great vigilance is required to ensure the
correct strength (dilution) of adrenaline is being used. Anaphylactic shock
kits need to make a very clear distinction, for example, between a 1:1000 and a
1:10,000 dilution and strength of adrenaline.
(9) Consider hydrocortisone IV 2-6 mg/kg.
(10) In the course of an allergic response to foreign antigens, immunoglobulins
are consumed and mast cell tryptase (and other acute phase reactants) are
released. Serial samples are required after the reaction; immediately after
treatment and at 1 and 6 hours after the reaction; post mortem sampling
is also possible. Blood samples, frozen at 4°
centigrade, should be dispatched with a full description of the
anaesthetic and the other clinical events.
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