Anaesthesia, surgery, and life-threatening allergic reactions: protocol and methods of the 6th National Audit Project (NAP6) of the Royal College of Anaesthetists

T M Cook; N J N Harper; L Farmer; T Garcez; K Floss; S Marinho; H Torevell; A Warner; N McGuire; K Ferguson; J Hitchman; W Egner; H Kemp; M Thomas; D N Lucas; S Nasser; S Karanam; K-L Kong; S Farooque; M Bellamy; A McGlennan; S R Moonesinghe

doi:10.1016/j.bja.2018.04.001

Anaesthesia, surgery, and life-threatening allergic reactions: protocol and methods of the 6th National Audit Project (NAP6) of the Royal College of Anaesthetists

Br J Anaesth. 2018 Jul;121(1):124-133. doi: 10.1016/j.bja.2018.04.001. Epub 2018 May 21.

Authors

T M Cook¹, N J N Harper², L Farmer³, T Garcez⁴, K Floss⁵, S Marinho⁶, H Torevell, A Warner⁷, N McGuire⁸, K Ferguson⁹, J Hitchman³, W Egner¹⁰, H Kemp¹¹, M Thomas¹², D N Lucas¹³, S Nasser¹⁴, S Karanam¹⁵, K-L Kong¹⁵, S Farooque¹⁶, M Bellamy¹⁷, A McGlennan¹⁸, S R Moonesinghe¹⁹

Affiliations

¹ Royal United Hospital, Bath, UK; University of Bristol School of Medicine, Bristol, UK; Health Services Research Centre, Royal College of Anaesthetists, London, UK. Electronic address: timcook007@gmail.com.
² Health Services Research Centre, Royal College of Anaesthetists, London, UK; Manchester University NHS Foundation Trust, Manchester, UK; Manchester Academic Heath Science Centre, University of Manchester, Manchester, UK.
³ Health Services Research Centre, Royal College of Anaesthetists, London, UK.
⁴ Manchester University NHS Foundation Trust, Manchester, UK (United Kingdom Fatal Anaphylaxis Register).
⁵ Anaesthetics and Critical Care, Oxford University Hospitals NHS Trust, Oxford, UK (Royal Pharmaceutical Society of Great Britain).
⁶ Manchester University NHS Foundation Trust, Manchester, UK (British Society of Allergy and Clinical Immunology).
⁷ Allergy UK (Allergy UK), London, UK.
⁸ Medicines and Healthcare products Regulatory Agency, London, UK.
⁹ Aberdeen Royal Infirmary, Aberdeen, UK (Association of Anaesthetists of Great Britain and Ireland).
¹⁰ Sheffield Teaching Hospitals NHS Trust, Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Shefield, UK (Royal College of Physicians/Royal College of Pathologists Joint Committee on Immunology and Allergy).
¹¹ Imperial College London, UK (Research and Audit Federation of Trainees).
¹² Great Ormond Street Hospital, London, UK (Association of Paediatric Anaesthetists of Great Britain and Ireland).
¹³ Northwick Park Hospital, Harrow, UK (Obstetric Anaesthetists Association).
¹⁴ Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK (British Society for Allergy and Clinical Immunology).
¹⁵ Sandwell and West Birmingham NHS Trust, Birmingham, UK.
¹⁶ Imperial College Healthcare NHS Trust, London, UK.
¹⁷ Leeds Teaching Hospitals NHS Trust, Leeds University, Leeds, UK (Faculty of Intensive Care Medicine).
¹⁸ Royal Free London NHS Foundation Trust, London, UK.
¹⁹ University College Hospital London NHS Trust, London, UK.

PMID: 29935564
DOI: 10.1016/j.bja.2018.04.001

Abstract

Background: Anaphylaxis during anaesthesia is a serious complication for patients and anaesthetists.

Methods: The Sixth National Audit Project (NAP6) of the Royal College of Anaesthetists examined the incidence, predisposing factors, management, and impact of life-threatening perioperative anaphylaxis in the UK. NAP6 included: a national survey of anaesthetists' experiences and perceptions; a national survey of allergy clinics; a registry collecting detailed reports of all Grade 3-5 perioperative anaphylaxis cases for 1 yr; and a national survey of anaesthetic workload and perioperative allergen exposure. NHS and independent sector (IS) hospitals were approached to participate. Cases were reviewed by a multi-disciplinary expert panel (anaesthetists, intensivists, allergists, immunologists, patient representatives, and stakeholders) using a structured process designed to minimise bias. Clinical management and investigation were compared with published guidelines. This paper describes detailed study methods and reports on project engagement by NHS and IS hospitals. The methodology includes a new classification of perioperative anaphylaxis and a new structured method for classifying suspected anaphylactic events including the degree of certainty with which a causal trigger agent can be attributed.

Results: NHS engagement was complete (100% of hospitals). Independent sector engagement was limited (13% of approached hospitals). We received >500 reports of Grade 3-5 perioperative anaphylaxis, with 266 suitable for analysis. We identified 199 definite or probable culprit agents in 192 cases.

Conclusions: The methods of NAP6 were robust in identifying causative agents of anaphylaxis, and support the accompanying analytical papers.

Keywords: National Audit Project; allergy; anaesthesia; anaphylaxis.

MeSH terms

Anaphylaxis / epidemiology*
Anaphylaxis / therapy
Anesthesia / adverse effects*
Anesthetics / adverse effects*
Drug Hypersensitivity / epidemiology*
Drug Hypersensitivity / therapy
Humans
Incidence
Medical Audit / methods*
Perioperative Period
Registries
Research Design
Surveys and Questionnaires
United Kingdom / epidemiology

Substances

Anesthetics