An Interdisciplinary Approach to Perioperative Anaphylaxis: A Tertiary Pediatric Center Experience
Saturday, March 5, 2016
South Exhibit Hall H (Convention Center)
Atoosa Kourosh, MD, MPH, Karen Thursday S. Tuano, MD, Dipika Patel, MD, Nicholas Rider, DO, Sara Anvari, MD, Lenora M. Noroski, MD, MPH, Kristin H. Dillard, MD, Filiz O. Seeborg, MD, MPH
Rationale: The estimated incidence of peri-operative anaphylaxis (PA) is 1:3,500-1:20,000. Although rare, PA causes morbidity and poses significant risk of mortality (3-9%). The most common causal agents are neuromuscular blocking agents, antibiotics and latex. In the operative setting, patients are exposed to multiple intravenous, inhaled and topical agents in rapid succession. Unless the cause of PA is quickly identified necessary procedures will be delayed.

Methods: Retrospective chart review for one year at Texas Children's Hospital included 8 patients with confirmed PA (5 cardiac, 1 dental, 1 radiology, 1 tonsillectomy). Skin prick and intradermal testing (ST) were performed with exposed agents and additional medications in collaboration with surgery teams for upcoming surgeries.

Results: Most common presenting symptoms were bronchospasm, hypotension and urticaria. Positive ST were found to Vecuronium, Cefazolin, Vancomycin, Midazolam, Ketamine, Methylprednisolone, Triamcinolone, Chlorhexidine, Fentanyl and Morphine. Vancomycin and Triamcinolone were not exposures but tested prior to upcoming procedures based on collaborative plans. Of 3 patients ST positive to opioids, 2 subsequently tolerated Morphine challenge. Vecuronium, Cefazolin, Midazolam, Ketamine, Chlorhexidine and Methylprednisolone were identified as true causal agents and avoided.

Conclusions: In addition to common causal agents in PA, more unusual agents like steroids and topical agents besides latex should also be investigated. Since drugs such as Vancomycin and opioids can produce false positive ST, graded challenge may be required to validate ST when alternatives are unavailable. An interdisciplinary team approach with close collaboration between allergy, anesthesia and surgical teams is key to planning the diagnostic work-up and advancing to surgery safely and expeditiously.