Anaesthesia, surgery, and life-threatening allergic reactions: epidemiology and clinical features of perioperative anaphylaxis in the 6th National Audit Project (NAP6)

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

doi:10.1016/j.bja.2018.04.014

Anaesthesia, surgery, and life-threatening allergic reactions: epidemiology and clinical features of perioperative anaphylaxis in the 6th National Audit Project (NAP6)

Br J Anaesth. 2018 Jul;121(1):159-171. doi: 10.1016/j.bja.2018.04.014. Epub 2018 May 21.

Authors

N J N Harper¹, T M Cook², T Garcez³, L Farmer⁴, K Floss⁵, S Marinho⁶, H Torevell, A Warner⁷, K Ferguson⁸, J Hitchman⁴, W Egner⁹, H Kemp¹⁰, M Thomas¹¹, D N Lucas¹², S Nasser¹³, S Karanam¹⁴, K-L Kong¹⁴, S Farooque¹⁵, M Bellamy¹⁶, N McGuire¹⁷

Affiliations

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

PMID: 29935567
DOI: 10.1016/j.bja.2018.04.014

Abstract

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

Methods: The 6th National Audit Project (NAP6) on perioperative anaphylaxis collected and reviewed 266 reports of Grades 3-5 anaphylaxis over 1 yr from all NHS hospitals in the UK.

Results: The estimated incidence was ≈1:10 000 anaesthetics. Case exclusion because of reporting delays or incomplete data means true incidence might be ≈70% higher. The distribution of 199 identified culprit agents included antibiotics (94), neuromuscular blocking agents (65), chlorhexidine (18), and Patent Blue dye (9). Teicoplanin comprised 12% of antibiotic exposures, but caused 38% of antibiotic-induced anaphylaxis. Eighteen patients reacted to an antibiotic test dose. Succinylcholine-induced anaphylaxis, mainly presenting with bronchospasm, was two-fold more likely than other neuromuscular blocking agents. Atracurium-induced anaphylaxis mainly presented with hypotension. Non-depolarising neuromuscular blocking agents had similar incidences to each other. There were no reports of local anaesthetic or latex-induced anaphylaxis. The commonest presenting features were hypotension (46%), bronchospasm (18%), tachycardia (9.8%), oxygen desaturation (4.7%), bradycardia (3%), and reduced/absent capnography trace (2.3%). All patients were hypotensive during the episode. Onset was rapid for neuromuscular blocking agents and antibiotics, but delayed with chlorhexidine and Patent Blue dye. There were 10 deaths and 40 cardiac arrests. Pulseless electrical activity was the usual type of cardiac arrest, often with bradycardia. Poor outcomes were associated with increased ASA, obesity, beta blocker, and angiotensin-converting enzyme inhibitor medication. Seventy per cent of cases were reported to the hospital incident reporting system, and only 24% to Medicines and Healthcare products Regulatory Agency via the Yellow Card Scheme.

Conclusions: The overall incidence of perioperative anaphylaxis was estimated to be 1 in 10 000 anaesthetics.

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

MeSH terms

Adolescent
Adult
Aged
Aged, 80 and over
Anaphylaxis / epidemiology*
Anaphylaxis / mortality
Anaphylaxis / physiopathology*
Anesthesia / adverse effects*
Child
Child, Preschool
Drug Hypersensitivity / epidemiology*
Drug Hypersensitivity / mortality
Drug Hypersensitivity / physiopathology*
Female
Heart Arrest / epidemiology
Heart Arrest / etiology
Humans
Incidence
Infant
Infant, Newborn
Male
Medical Audit
Middle Aged
Perioperative Period
Surgical Procedures, Operative / adverse effects*
United Kingdom / epidemiology
Young Adult