Intraoperative Anaphylaxis - Guidelines for Crises in Anaesthesia • Unexplained hypotension • Unexplained bronchospasm (wheeze may be absent if severe) • Unexplained tachycardia or bradycardia • Angioedema (often absent in severe cases) • Unexpected cardiac arrest where other causes are excluded • Cutaneous flushing in association with one of more of the signs above (often absent in severe cases) ❶ Call for help. Note the time. Stop or do not start non-essential surgery. ❷ Call for cardiac arrest trolley, anaphylaxis treatment pack and investigation pack. ❸ Remove all potential causative agents and maintain anaesthesia. • Important culprits: antibiotics, neuromuscular blocking agents, patent blue. • Consider chlorhexidine as cause (impregnated catheters, lubricants, cleansing agents). • Consider i.v. colloids as a possible cause. • Change to inhalational anaesthetic agent (if not already). ❹ Give 100% oxygen and ensure adequate ventilation: • Maintain the airway and, if necessary, secure it with tracheal tube. ❺ Elevate patient’s legs if there is hypotension. ❻ If systolic blood pressure < 50 mmHg or cardiac arrest, start CPR immediately. ❼ Give drugs to treat hypotension (Box A): • Hypotension may be resistant and may require prolonged treatment. • Give adrenaline bolus and repeat as necessary. • Consider starting an adrenaline infusion after three boluses. • If hypotension resistant, give alternate vasopressor (e.g. metaraminol, noradrenaline infusion +/ vasopressin) • Give glucagon in ß-blocked patient unresponsive to adrenaline. ❽ Give rapid i.v. crystalloid: 20 ml.kg-1 initial bolus, repeated until hypotension resolved. ❾ Give hydrocortisone as part of resuscitation (Box B). ❿ If bronchospasm is persistent, consider → 3-4 ⓫ Take 5-10 ml clotted blood sample for serum tryptase as soon as patient is stable. • Plan for repeat sample at 1-2 hours and >24 hours. ⓬ Give chlorphenamine when feasible (Box B). ⓭ Plan transfer of the patient to an appropriate critical care area. Note tasks in Box D. ⓮ Prevent re-administration of possible trigger agents (allergy band, annotate notes/drug chart) By Association of Anaesthetists @ https://twitter.com/AAGBI Quick Reference Handbook - Guidelines for crises in anaesthesia #Anaphylaxis #Anesthesiology #Anesthesia #Intraoperative #Checklist #Diagnosis #Management #Workup
