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Allergic Reactions Management Handout Read Only

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					                                                                  2/28/11




Allergy, Anaphylaxis,
   and Anesthesia




    Charles R. Barton, CRNA, MSN, M.Ed.
      Director, Graduate Anesthesia Program
     The University of Akron College of Nursing
                    Akron, Ohio




       Allergic to Tattoo Pigment
                              •  Edematous plaques confined
                                   to the areas of injection of
                                   tattoo pigment
                              •    32-year-old man developed
                                   an itchy painful eruption
                                   overlying a tattoo completed
                                   the previous day
                              •    The artist used only dark
                                   pigment
                              •    Eruption probably
                                   represents an allergic
                                   reaction to the pigment
                              •    May become a keloid scar.




Urticaria is an Eruption of Skin Wheals
   Due to increased capillary and Venule Permeability




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                   Urticarial Lesions
                                                  •  Urticaria occurs
                                                       following release of
                                                       histamine,
                                                       bradykinin,
                                                       kallikrein, or
                                                       acetylcholine
                                                  •    Resuls in intradermal
                                                       edema from capillary
                                                       and venous
                                                       vasodilation
                                                  •    Also, occasional
                                                       leukocyte infiltration.




       Gel and Coombs Classification of
           Immunological Reactions
  Type I                                Type II
     –  Immediate hypersensitivity        –  Cytotoxic – IgE, IgM
     –  Antigen binds with IgE               mediated
     –  Release of mast cell              –  Release of anaphylatoxins
        mediators                            with cellular destruction
     –  Results in anaphylaxis with       –  Occurs with transfusion
        wheal and flair response             reactions, hemolytic anemia,
                                             and Rh disease




    Gel and Coombs Classification
Type III                               Type IV
  –  Immune complex
                                         –  Delayed hypersensitivity
  –  IgG, IgM binds antigen and
                                         –  Ig antibodies not involved
     deposits in small blood vessels
                                         –  Sensitized thymus-derived
  –  Complement is activated with
                                            lymphocytes bind antigen and
     cellular destruction
                                            release effectors
  –  Possible causes include serum
                                         –  Examples are contact dermatitis
     sickness, glomeruonephritis,
                                            and tuberculin immunity
     and Hashimoto's thyroiditis




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    Drugs implicated in Anaphylactic and
          Anaphylactoid Reactions
                                            •  Antibiotics:
                                               –  PCN, cephalosporins,
                                                  vancomycin
                                            •  Blood products
•  Induction agents:                            –  Colloid volume expanders
                                            •  Chymopapain
   –  Propofol, barbiturates &
      etomidate                             •  Cyclosporin
•  Local anesthetics:                       •  Drug additives:
    –  esp. ester-based                     •  Mannitol, sulfites,
•  NMBAs                                       methylparabens
•  Narcotics:                               •  Protamine
   –  morphine, codeine, meperidine         •  Radiocontrast dyes




                                       Madame Curie
                                           (1867-1934, Born in Poland)


                                 •      Nothing in Life
                                      is to be Feared,
                                      only to be
                                      Understood.
 Discovered Radium
 and Polonium




   Had She only Known the Hazards!

                                      •  Marie Curie won the Nobel
                                           prize twice for her work with
                                           Radium and Polonium
                                      •    Safe handling of hazardous
                                           materials was not an issue then
                                      •    Her work isolating rare
                                           radioactive compounds
                                           probably lead to her death
                                           caused by leukemia
     Her outfit today!




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 Definition of Terms
  •  Antigen – Molecule capable of
       stimulating an immune response when
       contact through injection or other
       exposure
  •    Antibodies – are complex protein macromolecules
       produced by plasma cells and some lymphocytes that
       are capable of binding with antigens

  •  Specificity – quality of antibodies needed to bind with
       antigen like a lock & key – on a second exposure to
       an antigen locking will occur causing anaphylaxis




       PCN




                   Antigen
                   (Drug-Substance)

   Lymphoid tissue
   Plasma cell

       Response


                  Antibody
                  IgE




             Anaphylaxis Locking

          ECF-A                                    PAF



    Ca++                          Mast Cell
                                                          Histamine
Prostaglandins

                  SRS-A                       Serotonin
                                      Mg++




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Role of IgE in Activation of Allergic Inflammation



                                Mast cell
                              degranulation




                                                Over hours
 Immediate Release                              Cytokine production
 Granule contents:
 Histamine, Proteases,      Over minutes
 Heparin                    Lipid mediators:
                            Prostaglandins,
                            Leukotrienes




      Predominate Signs of Anaphylaxis
 •  Cardiovascular: hypotension, tachycardia, supraventricular
    or ventricular arrhythmias, absence of pulse - In awake
    individual: lightheadedness or loss of consciousness

 •  Respiratory: coughing or wheezing (bronchospasm),
    hoarseness or stridor (laryngeal edema), rales and
    pulmonary edema (increased tissue permeability and
    fluid shifts

 •  Cutaneous: Piloerection, urticaria, itchy
    and edematous eyelids




                         Target Shock
                            Organ
     • Some variability between as to which shock
       organ is affected by anaphylaxis
     • Within minutes cardiovascular fluid shifts and
       pulmonary dysfunctions develop
     • The respiratory system is most commonly
        associated with fatal reactions – angioedema of
        the glottis and epiglottis leads to airway
        obstruction and hyperinflation (like status
        asthmaticus)




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Protocol for Management of Anaphylaxis
                                                    Choice
•  Terminate injection                      Drug of
•  Administer 100% oxygen
•  Discontinue all anesthetic agents
•  Administer epinephrine:
•  50-100 µgm (.5-1.0 ml of 1:10,000 solution) I.V. to
   treat hypotension
•  100 µgm to 1 mg for cardiovascular collapse
•  Rapid volume expansion (crystalloid/colloid) 10-25
   ml)
•  Secure airway as appropriate – CPR if needed




               Epinephrine
• Sympathomimetic with alpha and beta activity
• Relaxes bronchial smooth muscle –beta effect
• Reduces edema of the upper airway, glottis
• Increases C.O. and SVR to improve perfusion
• Initiates vasoconstriction to combat
  vasodilation
• Adenyl cyclase activity is potentiated,
 increasing cyclic AMP to inhibit the release of
 mediators of anaphylaxis




            Adjunctive Therapy
              (Following Epinephrine)
• Isoproterenol – for refractory bronchospasm
• Dopamine – for hypotension, slow heart rate
• Norepinephrine – refractory hypotension and
  tachycardia
• Bronchodilators - beta
                       2 specific agonists
  inhalers and aminophylline for persistent
  bronchospasm




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             More Adjunctive Therapy

 • H-1 blockers (diphenhydramamine =
    Benadryl)
 • H-1 blockers (ranitidine, famotidine)
 • Steroids - Cortisol (Solu-Cortef) 1 gm I.V.
 • NaHCO for acid-base disturbances as per
                   3
    ABG assessment




                                                           Signs and
                                                          Symptoms of
                                                          Anaphylaxis

•  Itching.
•  Raised, red bumps on the skin (hives or wheals).
•  Wheezing or difficulty breathing.
•  Swelling, either in one area or over the entire body.
•  Swelling is most serious when it involves the lips, tongue, mouth, or throat and
   interferes with breathing.
•  Abdominal cramps.
•  Low blood pressure, shock, and unconsciousness.




                         Anaphylaxis
                                                     • Periorbital edema
                                                     • May have glottic
                                                       edema
                                                     • Need to treat
                                                       immediately
                                                     • Epinephrine is the
                                                         first-line drug of
                                                         choice




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                       Mast Cell
                     Degranulation
                •  Occurs when antigen
                     attaches to the
                     antibodies on the mast
                     cell
                •    This bridging of antigen
                     across antibodies causes
                     degranulation of the
                     mast cell with release of
                     mediators




Clinical Effects of Anaphylaxis
          Drug becomes
          an antigen in
          a susceptible
          patient



          Resulting in:
          bronchospasm,
          cardiovascular
          collapse, and
          hives




     Allergic Rhinitis
          (Hayfever)
             •  When hayfever sufferers inhale pollen,
                they produce special antibodies that
                stick to the pollen grains. These clumps
                then stick to cells lining the nose, throat
                and lungs, causing a sudden release of
                chemicals, including histamine, by the
                body. This 'red-alert' signal usually
                switches on only when the body is
                infected or injured. It triggers
                inflammation, which causes the
                symptoms of hayfever.




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            Allergy
•  Allergy can be described as a
     malfunction of the human immune
     system causing a violent reaction
     against normally harmless               Ryegrass Allergen
     substances
•    Today, the word allergy is
     considered to be a nonspecific term
     for acquired or induced
     susceptibility of a subject to an
     antigen (allergen)




                        Nettle Rash
                        (hives, urticaria)


                          Touch this

                               Get this


      Stinging Nettle




      Anaphylaxis

• From Greek term       ana meaning against and
      phylaxis meaning protection – together meaning
      against prophylaxis
•    Term coined in 1902 by Charles Robert Richet, a
     French physiologist - used to describe profound
     shock and subsequent death of some dogs when
     rechallenged with injection of sea anemone toxin




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              Anaphylaxis
• An immediate hypersensitivity reaction
• Characterized by a severe generalized
     immunological response with cardiovascular
     collapse, bronchospasm, and urticaria
•    Classified as a Type I immunological reaction
•    Requires previous exposure to the offending
     substance




           Immunological Reactions
     •  Involves the interaction
          between an antigen and
          antibody
     •    Reproducible when
          specific antigen is
          reintroduced into the
          patient
     •    Anaphylaxis is a
          immunoglobulin E (IgE)
          antibody reaction




                                         Mast Cell
                                       Degranulation
                                      Spewing histamine
                                      and other mediators of
                                      anaphylaxis into the
                                      tissues and blood
                                      stream




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                Demographics of
              Anaphylactic Reactions
 • 500 drug anaphylaxis deaths in US hospitals
     yearly
 • Anaphylaxis with anesthesia: 1:1,500 to 1:5,000
     with mortality of 1:40,000
 • Highest cause of anaphylaxis during anesthesia
     is neuromuscular blocking agents –
     Succinylcholine is highest culprit by far




          Anaphylactoid Reaction
•  Clinically indistinguishable
     from anaphylaxis – mimics
     anaphylaxis
•    Not dependent on production
     of antibodies
•    Not caused by an IgE-
     mediated response
•    Can occur on first exposure
     to drug or substance




           Histamine
•  Mediator released during
   allergic reactions
•  Stored in tissue mass cells
     and circulating basophils –
     human lung, intestines, and
     skin contain high
     concentrations
•    5-10% of total weight of
     mass cells is comprised of
     histamine




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                                             Allergic Rhinitis
                                                     (hayfever)




•  One in five people have hayfever - an allergy to pollen
•  Others possible allergens - dust mites, nuts, strawberries or bee
     stings
•  The body tends to get rid of anything unfamiliar – harmful or not
•  Usually, harmless invaders are destroyed by defender cells.
•  But in some people they trigger an allergic reaction because their
     immune system is too sensitive.




              Allergic Conjunctivitis
                                        •  Variant of       hayfever that
                                             basically causes redness,
                                             tearing, and itching of the eyes
                                        •    Responds to avoidance of
                                             allergens (pollen, etc.)
                                        •    Rx: topical or oral
                                             antihistamines, oral NSAIDs,
                                             mast cell stabilizers,
                                             leukotriene inhibitors
                                        •    Steroid eye drops for severe
                                             symptoms (potential side-
                                             effects e.g., glaucoma)




        Urticaria
     (Response to histamine)


 One of many potential causes:
•  Scombroid fish poisoning is a toxic reaction to decomposing
     scombroid fish, such as mackerel, tuna, bonito and butterfly kingfish
•  Scombroid fish contain a chemical called histadine. Bacteria multiply
     in fish stored in warm conditions (>15C) and turn the histadine into
     scombrotoxin. The main component of scombrotoxin is histamine
•    Cooking or smoking the fish does not reduce histamine levels




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                   Angioedema

               •  Angioedema
                  Angioedema is a nonpruritic,
                  painful swelling of loose
                  connective tissues that is
                  generally found on the face,
                  involving eyelids and lips, but
                  can also occur on the tongue
                  and in the extremities. If
                  angioedema involves the
                  larynx, it can be life-
                  threatening. In the acute
                  setting, it can occur with
                  urticaria.




             Dermographism
       •  Increased level of mast cells in
            the skin
       •  Hives occur when the skin is
            rubbed or scratched, or when
            irritated by tight clothing
       •    Very common (1/600 people)




Cold Urticaria
    •  Cold air, immersion in cold
       water, cooling of the skin while
       sweating (uncommon)
    •  The major significance of this
       condition is the risk of severe
       allergic reaction with whole body
       cooling such as when swimming
       in cold water
    •  Give blood warmed – to avoid
       problems with cold agglutinins
       (antibodies to cold)




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•  Poor potency
•  Misadministration
•  Keep the epinephrine pen
   away from small children
•  If epinephrine is accidentally
   injected into the wrong place,
   particularly the hand, seek
   medical attention
   immediately.
•  It will reduce the blood supply
   to the area and may become
   ischemic




        Testing for Allergies




    Skin Testing for Allergies




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                                               2/28/11




        Conclusions
• Allergic Reactions can range from mild to
 life-threatening in intensity
• 
 Awareness of the signs and symptoms are
 critical to early recognition and treatment
• 
 Appropriate treatment is essential to
 successful management during anesthesia
 administration




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