Is There An Allergy Skin Test For Fentanyl

Propofol and fentanyl induced perioperative anaphylaxis

N. Belső,

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Editor—Although rare, perioperative anaphylaxis can lead to astringent cardiorespiratory dysfunction or death. Numerous agents take been identified as triggers: the well-nigh mutual being neuromuscular blocking drugs, latex, and antibiotics. In contrast, sedatives, local anaesthetics, and opioids rarely cause anaphylaxis. The incidence of perioperative anaphylaxis ranges from 1:5000 to 1:25 000 and its mortality rate is three.4%.^1,ii Clinical signs are oftentimes hard to recognize considering they may be masked by the effect of administered drugs. Subsequently a reaction, a clear description of the presenting clinical symptoms together with a thorough instance history, in vivo tests (histamine releasing and serum tryptase tests), in vitro tests (specific IgE assay, basophil activation assay, and detection of CD63 expression in the presence of the allergen), skin tests (prick skin test, intradermal test), and drug provocation test are useful in determining the right diagnosis.^iii–6

A 25-yr-old man with a history of acne inversa was admitted for surgery to our department. The patient had childhood asthma, otherwise his past medical history was unremarkable, and no drug allergy was known. Nigh 10 min after induction of anaesthesia with propofol, fentanyl, and rocuronium, the patient adult ventilatory difficulty, with wheezing, poor expiration, copious frothy secretions from the tracheal tube, and oxygen saturation decreased. Theophylline was given i.v. and the bronchospasm improved, but a significant corporeality of frothy secretion was removed from the trachea. Later extubation, he could not coughing up the tracheal secretion and saturation decreased from 97% to 80%. Reintubation, repeated removal of secretion, and i.v. hydrocortisone was administered. Oxyhaemoglobin saturation was 97–98% after re-extubation, just some bronchospasm was withal detectable. The surgery was cancelled. The anaesthetist initiated an investigation of the patient. Lymphocyte transformation examination (LTT) was positive for fentanyl and propofol. The test for rocuronium, the third drug in question, was negative. To detect replacement drugs to be safely administered during the next surgery, we also performed LTTs with potentially usable anaesthesia-inducing agents. Of these, LTT was positive for etomidate, and negative for thiopental, paracetamol, and diclofenac–orfenadrin. The skin-prick testing showed an increased sensitivity to meperidine; epicutaneous patch tests for fentanyl, etomidate, and thiopental showed no signs of allergic reaction. We performed the skin-prick test with the original formula of the injection, for patch tests drugs were mixed with vaseline and applied on the skin in occlusion. We used epicutaneous tests instead of skin-prick tests for tissue toxic agents. The next surgery was carried out in accordance with the examination results and the surgery went on without incident, and the patient was discharged from the infirmary on the sixth postoperative day.

Opioid-induced anaphylaxis is rare; to engagement, there have been vii reported cases of fentanyl-induced anaphylaxis.

In our case, the patient showed hypersensitivity to: fentanyl (positive LTT) and meperidine (positive skin prick test), but tolerated the semi-constructed analogue: nalbuphine (in vivo administration). Although meperidine can cause pseudo-allergic reaction, therefore 'false' positive prick tests, our patient's strong skin reaction compared with command persons indicated a truthful hypersensitivity (Fig.1).

Fig 1

(a) The patient's skin-prick testing showed increased sensitivity to meperidine (H, histamine; K, control; D, meperidine). (b) In not-allergic control, skin-prick testing showed a reaction slightly larger than the negative control, but smaller than the histamine reaction (H, histamine; K, control; D, meperidine).

The case demonstrates the importance of drug allergy examinations in perioperative anaphylaxis and the being of rare fentanyl and propofol induced astringent reactions. Our patient's case was further complicated by the patient'due south hypersensitivity to the non-barbiturate-type sedative propofol, which likely contributed to the onset of anaphylaxis during anaesthesia. Patients who experience perioperative anaphylaxis demand a thorough examination for drug allergy. The evaluation should include a precise clinical history, consideration of risk factors, and in vitro and in vivo drug allergy tests.

Conflict of involvement

None declared.

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Comments

ane Comment

The suspected anaphylactic shock caused past reptilase during urology surgery

28 Feb 2012

Qiang Fu (with W.-D.Mi, and H.Zhang)

associate professor, Department of Anaesthesiology,General hospital of PLA

Editor - I had read the article written by Belso N. with great interest (published in Br J Anaesth 2011;106:283). Neuromuscular blocking drugs, opioid, propofol, latex and antibiotics take been reported to induced anaphylaxis.1Anaphylactic stupor caused by reptilase is extremely rare. The incidence of perioperative anaphylaxis ranges from 1:5000 to 1:25000 and its mortality rate is 3.iv%.ii Haemocoagulase atrox for injection (Reptilase, Solco Basle Ltd., Switzerland) could promote the formation of active thrombin, which is an constructive hemostatic drug with petty side upshot and is widely used in our department. A 36-yr-erstwhile women was admitted for left kidney tumor enucleation. She was diagnosed with renal angiomyolipoma. No drug allergy history was known. Preoperative claret force per unit area (BP) and electrocardiogram was normal. Amazement was induced and maintained with propofol, sufentanil and vecuronium. From the beginning of surgery to 1.5 hours later, general anaesthesia proceeded uneventfully, and after 100ml bleeding, the patient was kept in a stable haemodynic status past transfusion with crystalloid. When blood exudation was found in left kidney wound, ii KU Reptilase was injected intravenously. A few minutes later, systolic arterial force per unit area dropped from 120 to 45 mm Hg and heart rate increased from 70 to 140 beats min-1 drastically. Nosotros speeded up fluid transfusion and intravenously infused with phenephrine. But vital signs was still unstable. Considering pulmonary thrombosis, urgent transoesophageal echocardiography (TOE) examination was performed by anaesthesiologist. But no obvious thrombosis was found in right atrial, right ventricular and main pulmonary avenue. At the same time, lots of urticaria was institute in her cervix and body torso. A diagnosis of anaphylactic shock was made, epinephrine, meprednisone and fluid resuscitation were used to restore circulation succesfully. Within 0.5 h afterward surgery, patient was awake and returned to the wards safely from operation room. She underwent a full recovery and was discharged from hospital 8 days later without sequelae. Reptilase is snake venom thrombin-like enzymes (SVTLEs).three Because the incidence rate of allergic reactions is very depression, Reptilase does not require peel allergy test. Only anaesthesiologists should pay close attention to drug response, and brand early detection of the occurrence of anaphylactic shock by observation of skin colour, vital signs and airway pressure level. TOE may have prominent role in perioperative acute cardiovascular collapse. 4 When BP drib occurs in a patient suddenly without significant blood loss, fluid therapy and vasoactive drugs like ephedrine, dopamine could not make a relief. In this situation, significant hemodynamic instabilities are known to occur, which require rapid identification and solution. TOE should performed immediately to detect intracardiac emboli or other heart anomaly. Patients who feel perioperative anaphylaxis during amazement need a thorough exam, which include a precise clinical history, skin examination (prick pare examination, intradermal test) , in vitro tests (specific IgE assay, basophil activation assay, detection of CD 63 expression) and in vivo drug allergy examination (histamine releasing and serum trptase tests).2,five In determination, adverse reactions of reptilase should be observed by clinicians, and proper treatment should be taken to forestall complications.

Disharmonize of interest: None declared.

Q,Fu*

Westward.-D.Mi

H.Zhang

Beijing,People's republic of china

*East-postal service:dr_fuqiang@hotmail.com

Refenrences: 1.Belso N, et al. Propofol and fentanyl induced perioperative anaphylaxis. Br J Anaesth 2011;106:283-284 2.Mertes PM, et al. Allergic reactions occurring during anesthesia. Eur J anaesth 2002;xix:240-62 3.Castro HC, et al. Structural features of a serpent venom thrombin-like enzyme: thrombin and trypsin on a single catalytic platform? Biochim Biophys Acta 2001; 1547:183-95 4.Bilotta F, et al. Perioperative transoesophageal echocardiography in noncardiac surgery. Ann Carte Anaesth 2006; 9:108-13 5.Laroche D, et al. Biochemical markers of anaphylactoid reactions to drugs. Comparing of plasma histamine and tryptase.Anesthesiology 1991;75:945-ix