Anesthetic drugs are associated with several common side effects that occur during and after surgery, including nausea and vomiting, chills and shivering, sore throat, muscle aches and itching.1 Depending on their health histories and the type of surgery, some patients may experience more severe complications related to respiratory, cardiovascular or other organ systems.2 An important risk of anesthesia is allergic reaction.2 Allergic reactions can range from mild reactions, such as a skin rash, to severe forms, which cause difficulty breathing.3 In order to care for patients, anesthesia providers should understand the signs of an anaphylactic allergic reaction, what they can do to prevent and treat such reactions and recent research on anaphylaxis during anesthesia.
Anaphylaxis is a severe, potentially fatal allergic reaction that can occur within seconds or minutes after exposure to an allergen.4 Anaphylaxis causes an autoimmune reaction in which a flood of chemicals leads the body to go into shock.4 Signs and symptoms include a sudden drop in blood pressure; narrowing of the airway and swelling of the tongue or throat, which can cause wheezing and trouble breathing; a weak and rapid pulse; skin reactions such as hives, itching and flushed or pale skin; dizziness or fainting; and nausea, vomiting or diarrhea.4 Fortunately, anaphylaxis reaction to anesthetic agents is rare, ranging from one in 4,000 to one in 25,000 cases.5 However, anaphylaxis can be particularly dangerous while under anesthesia, as it may be more difficult to observe the warning signs of allergic reaction such as lightheadedness and shortness of breath.3
Anesthesiology professionals can take steps to prevent and handle allergic reactions in the operating room. First, the anesthesia provider should be sure to collect an accurate medical history from the patient, including any allergies to drugs, foods, environments or materials.5 This history should encompass any past life-threatening complication that occurred during past anesthesia administration, as this could indicate an allergic reaction.6 Even if no allergies or past complications are reported, the anesthesia provider may opt to perform skin testing with the preferred anesthetic before the procedure.5 For example, research shows that thiopental allergy has been documented by skin tests.5 During a procedure, the anesthesia provider should keep a close eye on the patient’s vitals to detect any signs of anaphylaxis, such as cardiovascular collapse or airway obstruction.5,6 This is particularly important in the operating room environment, where skin rashes may be more difficult to identify.5 If a reaction does occur, the anesthesiology professional’s immediate reaction should be to withdraw the offending drug, provide aggressive pulmonary and cardiovascular support and inject the patient with epinephrine.7 Blood samples can be taken to determine serum tryptase, which indicates an allergic reaction and may help to prevent future reactions.6 The most important aspect of managing anaphylaxis during surgery is the safety of the patient.5
Several recent studies have approached the risk factors, anesthetic agents and management techniques associated with anaphylaxis during anesthesia. Contrary to popular believe, Dewachter et al. state that there is no reason to contraindicate propofol in egg-, soy- or peanut-allergic patients.8 Meanwhile, Mertes et al. found that adult women are at higher risk for allergic reactions from anesthesia.9 They also found that neuromuscular blocking agents (NMBAs), latex and antibiotics were most frequently related to anaphylaxis during surgery.9 Karila et al. found NMBAs and latex to be the most common causes of allergic reactions in French children,10 while Lobera et al. noted that antibiotics and NMBAs caused the most frequent reactions in Spanish patients.11 Currie et al. performed a retrospective study on an algorithmic approach to anaphylaxis during anesthesia.12 They found that the structured approach would have led to a quicker and/or better resolution to the problem in 30 percent of cases.12 Furthermore, Hepner et al. reviewed anaphylaxis in obstetric anesthesia, suggesting prompt epinephrine administration and emergency Cesarean delivery in third-trimester pregnancies.13 Finally, Laroche et al. performed a retrospective review of blood histamine and tryptase concentrations from patients who had life-threatening allergic reactions under anesthesia to those who were resuscitated from other types of shock.14 They found significantly higher concentrations of histamine and tryptase in the patients who had allergic reactions, indicating that these measures may have diagnostic value.14
Though anaphylaxis during anesthesia is uncommon, it can be fatal. Anaphylaxis reactions may be more difficult to diagnose while a patient is under anesthesia, so the anesthesiology professional must pay close attention to cardiac, pulmonary or airway changes in the patient. If anaphylaxis occurs, the anesthesia provider should withdraw the offending drug and perform resuscitative techniques. Clinicians should also study data on the risk factors, drug types and management strategies associated with anaphylaxis during anesthesia. Future research should approach anesthetic alternative to drugs that most frequently cause anaphylaxis.
1. American Society of Anesthesiologists. Effects of Anesthesia. When Seconds Count… Physician Anesthesiologists Save Lives 2020; https://www.asahq.org/whensecondscount/anesthesia-101/effects-of-anesthesia/.
2. Mayo Clinic. General anesthesia. Tests & Procedures December 4, 2018; https://www.mayoclinic.org/tests-procedures/anesthesia/about/pac-20384568.
3. Wang C. Allergic Reactions During Surgery. Canadian Anesthesiologists’ Society 2020; https://www.cas.ca/en/about-cas/advocacy/anesthesia-faq/allergic-reactions-during-surgery.
4. Mayo Clinic. Anaphylaxis. Tests & Procedures September 14, 2019; https://www.mayoclinic.org/diseases-conditions/anaphylaxis/symptoms-causes/syc-20351468.
5. Mali S. Anaphylaxis during the perioperative period. Anesthesia, Essays and Researches. 2012;6(2):124–133.
6. Michel MP, Pascal D, Rodolphe S. Perioperative Allergic Reactions. World Allergy Organization March 2019; https://www.worldallergy.org/education-and-programs/education/allergic-disease-resource-center/professionals/allergy-to-anesthetic-agents.
7. Hepner DL, Castells MC. Anaphylaxis During the Perioperative Period. Anesthesia & Analgesia. 2003;97(5):1381–1395.
8. Dewachter P, Mouton-Faivre C, Castells MC, Hepner DL. Anesthesia in the patient with multiple drug allergies: Are all allergies the same? Current Opinion in Anesthesiology. 2011;24(3):320–325.
9. Mertes PM, Demoly P, Malinovsky JM. Hypersensitivity reactions in the anesthesia setting/allergic reactions to anesthetics. Current Opinion in Allergy and Clinical Immunology. 2012;12(4):361–368.
10. Karila C, Brunet-Langot D, Labbez F, et al. Anaphylaxis during anesthesia: Results of a 12-year survey at a French pediatric center. Allergy. 2005;60(6):828–834.
11. Lobera T, Audicana MT, Pozo MD, et al. Study of hypersensitivity reactions and anaphylaxis during anesthesia in Spain. Journal of Investigational Allergology and Clinical Immunology. 2008;18(5):350–356.
12. Currie M, Kerridge RK, Bacon AK, Williamson JA. Crisis management during anaesthesia: Anaphylaxis and allergy. Quality and Safety in Health Care. 2005;14(3):e19.
13. Hepner DL, Castells M, Mouton-Faivre C, Dewachter P. Anaphylaxis in the Clinical Setting of Obstetric Anesthesia: A Literature Review. Anesthesia & Analgesia. 2013;117(6):1357–1367.
14. Laroche D, Gomis P, Gallimidi E, Malinovsky J-M, Mertes PM. Diagnostic Value of Histamine and Tryptase Concentrations in Severe Anaphylaxis with Shock or Cardiac Arrest during Anesthesia. Anesthesiology: The Journal of the American Society of Anesthesiologists. 2014;121(2):272–279.