Anaphylaxis UHL Anaesthetic Guideline

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1.Introduction
Anaphylaxis is a severe, life-threatening, generalized or systemic
hypersensitivity reaction. Anaphylaxis may be divided into ‘allergic
anaphylaxis’ and non-allergic anaphylaxis’. The clinical features of
allergic and non-allergic anaphylaxis may be identical.
Antibiotics are the most common trigger for anaphylaxis, followed
by muscle relaxants, chlorhexidine and Patent Blue dye.
The severity-grading of hypersensitivity reactions depends on signs

and symptoms. Minor or moderate reactions (Grade 1 and Grade 2)
are correctly termed ‘hypersensitivity’, and should not be called
‘anaphylaxis’ as only Grade 3, 4 and 5 hypersensitivity can correctly
be termed anaphylaxis.
Grade 1: is characterized by cutaneous features such as rash, itch

or peripheral swelling.
Grade 2: mild hypotension or wheeze (usually not requiring

treatment), with or without Grade 1 features.
Grade 3: hypotension or wheeze are severe, and may include

airway swelling.
Grade 4: fulfils the requirements for initiating cardiopulmonary

resuscitation.
Grade 5: is a fatal reaction.
Perioperative anaphylaxis is a clinical diagnosis, and presenting

features may have many other causes that are more frequent than
anaphylaxis. Despite this, early recognition and treatment of
anaphylaxis during anaesthesia is essential for avoiding harm.
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Guideline for the Management of Suspected Anaphylaxis During Anaesthesia
Author: Prea Ramasamy – Consultant Anaesthetist Trust Ref: C56/2016 Reviewed Dec 2018 Next Review Dec 2022
Approved by ITAPS Quaility and Saftey Board
2.Scope
The guidance applies to all anaesthetists who are responsible for

the clinical management and/ care of these patients.
3.Guideline Standards and Procedures
Anaphylaxis is likely when all the following criteria are met:
Sudden onset and rapid progression of symptoms
Life threatening Airway and/or Breathing and/or Circulation problems,
HYPOTENSION being the most frequent presenting feature
Skin and/or mucosal changes (flushing, urticarial, angioedema) are

uncommon presenting features.
Under Anaesthesia Common Signs include:
 HYPOTENSION
 BRONCHOSPASM
Inmediate Management
 Use ABCD approach
 Adrenaline is the mainstay of the treatment of anaphylaxis
 Remove Causative Agent
 Elevate Legs
 CALL FOR HELP AND INVESTIGATION BOX.
 IF SYSTOLIC BLOOD PRESSURE LESS 50mmHG start CRP
as ALS guidelines
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Recommendation/ Cautions
 Treatment
1-Adrenaline is the primary treatment of

anaphylaxis and should be administered immediately if
anaphylaxis is suspected. In the perioperative setting
this will usually be IV.
2-A rapid IV crystalloid (not colloid) fluid challenge of 20 ml/kg
should be given immediately. This should be repeated several
times if necessary.
3-If an IV colloid is being administered at the time of the

anaphylactic event, it should be discontinued, and the IV
administration set replaced.
4 -During anaphylaxis with a systolic blood pressure <50
mmHg in adults, even without cardiac arrest, CPR should be
started simultaneously with immediate treatment with
adrenaline and liberal IV fluid administration.
5-Vasopressin and glucagon for the management of

intractable perioperative anaphylaxis should be available
within 10 minutes, wherever anaesthesia is administered.
Details of locations are in RARE EMERGENCY DRUGS

LOCATIONS CHART WITHIN THEATRES AREAS UHL.
6-Administration of IV vasopressin 2 Units, dilute 20 units(1ml)
in 20 ml of Sodium Chloride 0.9% , repeated if necessary,
should be considered when hypotension due to perioperative
anaphylaxis is refractory.
7-During perioperative anaphylaxis in patients taking beta
blockers early administration of IV glucagon 1 mg should be
considered, repeated as necessary.
8-A corticosteroid should be administered as part of
resuscitation of perioperative anaphylaxis.
9 -Chlorphenamine may be given as part of the resuscitation

process, but NAP6 found no evidence of either benefit or harm. It
may reduce angioedema and urticarial.
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10-There remains uncertainty about the benefits or potential
harm of administering sugammadex during resuscitation of
perioperative anaphylaxis and for management of rocuronium
induced anaphylaxis specifically. Clinical trials would provide
valuable evidence.
11.-When anaphylaxis occurs following recent insertion of a

chlorhexidine coated central venous catheter, this should be
removed, and if appropriate replaced with a plain one.
12-Patients with severe anaphylaxis should be admitted to critical

care.
13-All patients with suspected anaphylaxis should be closely

monitored in PACU/SACU/HDU for a minimum of 6 - 12 hours
in case of late deterioration from a biphasic response.
14-Non-essential surgery should not be started after severe

perioperative anaphylaxis.
15-Where pulse oximeter saturations fall during anaphylaxis in a

patient who has received Patent Blue dye, hypoxia should be
assumed to be real. A blood gas sample should be taken, when
the patient is stable enough for this.
16-Latex related anaphylaxis – atypical late presentation often

occurs 30-60 minutes after contact. This is due to airborne
exposure or mucous membrane contact.
17-If an adverse reaction to blood or blood components is

suspected, return all components to the laboratory where
possible and inform the blood transfusion laboratory as per
protocol.
 Departmental Organization
-All cases of severe perioperative anaphylaxis, including

fatalities, should be discussed with an allergy clinic at the first
available opportunity.
-All cases of Grades 3–5 perioperative anaphylaxis should be

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presented and discussed at local Morbidity and Mortality meetings
for purposes of education and familiarization.
-Operating theatres should have an accessible list of chlorhexidine-

containing items. Appropriate alternatives should be available for
patients with suspected or confirmed chlorhexidine allergy.
-If administration of Patent Blue dye is planned during surgery, the

surgical team should discuss the risk of anaphylaxis as part of the
consent process for surgery.
-Investigation of perioperative anaphylaxis should include

follow-up, either in hospital or in primary care, to detect adverse
sequelae such as new anxiety, impairment of cognition or
activities of daily living or deterioration in cardiorespiratory or
renal function. The anaesthetic department lead should
coordinate this.
Investigations and referral to Allergy Clinic.
ANAESTHETIC ANAPHYLAXIS INVESTIGATION BOX CHECKLIST
Boxes should be in Recovery areas, ICUs, Maternity Suite, MRI, CTscan

and Catheter Suite Laboratory.
This pack contains:

1.-Guideline of the management of suspected anaphylaxis during
anaesthesia
2.-Details of where to find glucagon and vasopressin with details of
doses.Less than 10 minutes away.
3.-Instructions on taking three timed blood samples for mast cell
tryptase and forms.
4.-Stickers Anaesthetic Anaphylaxis Check List.
5.-Template for letter to be given to the patient.
6.- Template for letter to be sent to the GP.
7.-Referral form to be sent to the Allergy Clinic.
8.-Urgent surgery management plan.
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MAST CELL TRYPTASE
MAST CELL TRYPTASE (Blood test) SENT TO IMMUNOLOGY AT
0 hours 1-2 hours 24hours
Brown (serum) Bottle: Labelled with times
 It is anaesthetist responsibility to ensure the samples are

taken, including 24h sample
 Ensure you date and time the tubes. There is no need to
refrigerate the samples.
o 1st sample as soon as the patient is stable.
o 2nd sample as close as 1-2 hours as possible after the
event. (No more than 6h)
o 3rd baseline at least 24 hours after the event.
 Phone Immunology ( 6710) when you have taken the 2nd
sample so they expect a group of 3 samples.
COMMUNICATION AND FOLLOW UP
 Record full details of the anaphylaxis and resuscitation in the
patient’s medical record.
 Anaesthetic Anaphylaxis Check List Sticker (Investigation
box) to be added to patient notes.
 Suspected medication stopped and an alternative prescribed
on drug chart.
 Document potential allergens on wristband and drug chart.
 Explain to the patient what has happened as soon as
practicable and record your conversation in the medical
record. Give the patient the completed Patient Letter
(Appendix 2)
 Report the event in Datix System.
 Inform Perioperative Anaphylaxis Lead and Allergy Consultant
about suspected/ anaphylaxis via Anaphylaxis Anaesthetic
Mailbox. . (Anaesthanaphylaxis@uhl-tr.nhs.uk)
 Ensure the event is reported to the MHRA though the Yellow

Card system and keep a note of the MHRA Reference
Number to update with the Allergy Clinic diagnosis. You will
need this number for the Allergy Clinic Referral Form.
 Complete all parts of the Allergy Clinic Referral Form (
Appendix 1) and send together with photocopies of
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anaesthetic record, drug chart and other relevant
documentation to Allergy Consultant.
 Inform patient’s GP using GP letter.( Appendix 3 )
 If postponed surgery is urgent ,refer to Urgent Surgery
Management Plan.( appendix 4)
 Ensure the patient is followed up for adverse physical and or
psychological effects.
 Follow this link for Appendix 1, 2 and 3
https://www.leicestershospitals.nhs.uk/aboutus/departments-services/allergy/
All patients experiencing suspected perioperative anaphylaxis should

be referred for specialist investigation in an allergy clinic. This is the
responsibility of the Consultant Anaesthetist in charge of the patient
at the time of the event, i.e. the consultant anaesthetizing or supervising
the case.
Patients should be ideally seen by Allergy Clinic within 6 weeks.

The case should be discussed with the allergist prior the
appointment.
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ANAESTHETIC ANAPHYLAXIS INVESTIGATIONS
1.-Document in Medical Notes

2.-Anaesthetic Anaphylaxis Check List Sticker.
3.-Stop and document suspected medication in drug
chart and on wristband.
4.-Datix Form.
5.-Email Anaesthetic Anaphylaxis Mailbox
(Anaesthanaphylaxis@uhl-tr.nhs.uk)
6.-Report to yellowcard.mra.gov.uk and keep a note
of the MHRA Reference Number.
7.-Complete all parts of the Allergy Clinic Referral
Form and with photocopies of anaesthetic record,
and drug chart.
Respiratory Medicine
Dr Nasreen Khan
Glenfield Hospital Leicester 0116 287 1471
8.-Explain to patient and complete Patient Letter.

9.- Inform GP using GP letter.
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4.Education and Training
All anaesthetists responsible for perioperative care should be

trained in recognition and management of perioperative anaphylaxis
and relevant local arrangements.
Clinical Directors of anaesthetic departments should ensure their
anaesthetists have been trained in the management of perioperative
anaphylaxis.
5.-Monitoring and Audit Criteria
Element to
be Lead Method Frequency Reporting
Monitored Arrangements
Datix
Anaphylaxis ITAP Incidents All ITAPS Q&S Board
events Q&S and Audits Incidents
Lead
Email to
Anaesthetic Every ITAPS Q&S Board
Referral Anaesthetic Anaphylaxis 6 months and Immunology
Compliance Anaphylaxis Mailbox and Lead
Lead Allergy
Clinic
Follow Up
6.-Supporting References
RCUK 2016: Emergency treatment of anaphylactic reactions:

Guidelines for healthcare providers. Resuscitation council UK 2016.
https:/www.resus.org. uk/anaphylaxis/emergency-treatment-of-
anaphylactic- reactions/
MHRA 2012: All medical devices and medical products containing

chlorhexidine - risk of anaphylactic reaction due to chlorhexidine
allergy. Medicines and Healthcare Products Regulatory Agency
(2012) https:/www. gov.uk/drug-device-alerts/medical-device-alert-
all- medical-devices-and-medicinal-products-containing-
chlorhexidine-risk-of-anaphylactic-reaction-due-to- chlorhexidine-
allergy#action
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-AAGBI resources Allergies and Anaphylaxis where you can find
NAP 6 report, Quick Reference Handbook Card, link to the yellow
card, and link to British Society of Allergists and Clinic
Immunologists in the UK.
https://www.aagbi.org/safety/allergies-and-anaphylaxis
-Anaesthesia, Surgery and Life-Threatening Allergic Reactions

Report and findings of the Royal College of Anaesthetists’ 6th
National Audit Project: Perioperative Anaphylaxis May 2018.
- Australian and New Zealand College of Anaesthetists (ANZCA)

and Australian and New Zealand Anaesthetic Allergy Group
(ANZAAG). Perioperative Anaphylaxis Management Guidelines.
7.Key Words
Anaesthetic anaphylaxis; perioperative anaphylaxis; suspected

adverse drug reaction; drug allergy; suspected drug allergy;
mast cell tryptase, NAP 6.
8..
CONTACT AND REVIEW DETAILS
Guideline Lead (Name and Lead Committee or Executive Lead
Title) ITAPS Clinical Effectiveness Lead
Patricia Romero, Consultant
Anaesthetist P Ramasamy
Prea Ramasamy, Consultant

Anaesthetist
Details of Changes made during

Date of Next Review by review:
Approval Committee: Anaesthesia anaphylaxis investigation
April 2022 pack.
Details -IV crystalloid 20 ml/kg repeated.
-CPR if systolic BP<50mmHg(adults).
-Vasopressin 2 units in refractory
hypotension, repeat PRN.
-Early glucagon 1mg in beta-blocked
patients, repeat PRN.
-Harmonization of clinic diagnostic
pathways.
-Links provided for better accessibility
to Appendix documents
- Mailbox for anaesthetic anaphylaxis
APPENDIX 1
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NATIONAL AUDIT PROJECT 6
ANAESTHETIC ANAPHYLAXIS REFERRAL FORM ( 4 pages)
Perioperative Anaphylaxis
Patient details
Churchill House 35 Red Lion Square London WC1R 4SG
Name……………………………………………………………......................................................
020 7092 1677 nap6@rcoa.ac.uk
Date of birth …./…./…….. Hospital / NHS Number …………………………………...
Address …….………………………………………………………...............................................
…………………………………………………… Telephone ……………................……………...
Referring consultant anaesthetist (for clinic correspondence)
Name……………………………………………………………………………..….………………....
Address…………..………….………………………………………………………………...............
……………………………………………………………………… ....………………………………...
Telephone……………………………... Secure Email …………………………………………..
Patient’s GP (for clinic correspondence)
Name……………………………………………………………………………..….………………....
Address…………..………….………………………………………………………………...............
………………………………………………………………………. ...………………………………...
Surgeon (for clinic correspondence)
Name……………………………………………………………………………..….………………....
Address…………..………….………………………………………………………………...............
………………………………………………………………………. ...………………………………...
Date of the reaction.…./…../20....
Time of onset of Clinical Features ….../…...h (24h clock)
Suspected cause of the reaction (most likely first)
1) ……………………………... 2) …..…………….…………… 3) ….……………..………….…
Proposed surgical or other procedure: ………………………………………………...………..
Was surgery/procedure completed? Yes No
If ‘no’, has another date for surgery being scheduled? Yes No
Urgency/Date of future surgery.…………………………………………………………….........
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NATIONAL AUDIT PROJECT 6
TIMELINE 1: Drugs administered in the hour before the reaction. Please include any
Perioperative
other Anaphylaxis
relevant exposures, e.g. chlorhexidine, iv colloids, Patent Blue dye
Drugs and other Time (24 Route of drug Comments

Churchill House 35 Red Lionhour
Square Londonadministration
clock) WC1R 4SG
exposures
020 7092 1677 nap6@rcoa.ac.uk
Please continue on a separate page if you need to add more details
TIMELINE 2: Clinical features of the reaction and other relevant events. Please include
lowest BP, SpO2 and expired CO2.
Clinical Features and Events Time (24 hour clock) Comments
Please continue on a separate page if you need to add more details

2
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APPENDIX 2
LETTER TO THE PATIENT FOLLOWING PERIOPERATIVE ANAPHYLAXIS
Date:
Patient’s name:
Patient’s address:
Hospital Number:
NHS Number:
Planned Procedure:
Consultant Surgeon:
Consultant Anaesthetist:
Dear
You had a suspected severe allergic reaction(anaphylaxis) during anaesthesia on

To find out the cause of the reaction I will refer you to the anaesthetic allergy clinic at:
Dr. Nasreen Khan

Respiratory Consultant Allergy Clinic
Glenfield Hospital Leicester 0116 287 1471
They will contact you with an appointment –this normally takes a few weeks.
 If you have not heard in six weeks or if you have any queries please
contact me (details below).
 It is important you attend the allergy clinic to prevent a further severe

allergic reaction.
Until you have attended the allergy clinic, you should avoid all drugs and other
potential causes you were exposed to the hour prior the allergy reaction. These
include:
o Latex
o Chlorhexidine, including medical, dental and household products
o Anaesthetics drugs (specify)
o Antibiotics (specify)
o Analgesics (specify)
o Other drugs (specify
It is important that you show this letter if you have any medical appointments between
now and the time of your clinic appointment.
I will write to your GP with this information.
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Yours sincerely,
Consultant Anaesthetist Contact phone number
APPENDIX 3
LETTER TO THE PATIENT’S GP FOLLOWING PERIOPERATIVE ANAPHYLAXIS
Date:
GP’S name and Address:
Dear Dr
Your patient:
Address:
Hospital Number:
NHS Number:
Planned Procedure:
Consultant Surgeon:
Consultant Anaesthetist:
Had a suspected severe allergic reaction (anaphylaxis) during anaesthesia on
Your patient has been referred for investigation to the anaesthetic allergy clinic at
Dr Nasreen Khan,
Respiratory Consultant
Allergy Clinic
Glenfield Hospital, Leicester, LE3 9QP
01162871471
Until the patient has attended the allergy clinic, they should avoid all drugs and
potential allergens to which they are exposed during the hour prior the allergic
reaction. These include:
o Latex
o Chlorhexidine, including medical, dental and household products
o Anaesthetics drugs (specify)
o Antibiotics (specify)
o Analgesics (specify)
o Other drugs (specify
I have given the patient a letter providing the same information as here.
Yours sincerely,
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Consultant Anaesthetist
Contact Phone Number
APPENDIX 4
Urgent surgical intervention after suspected perioperative

anaphylaxis and prior to allergy investigations: suggested
management.
It is possible to provide a safe anaesthesia in almost every case and

unnecessary to postpone surgery.
 It is important to discuss the case with a consultant Allergist or

Clinical Immunologist as soon as possible after the suspected
anaphylactic event.
 Regional anaesthesia, where practical may be a sensible

option to enable avoidance of most drugs suspected to have
caused anaphylaxis during previous general anaesthesia.
 If anaesthesia was induced with propofol and general

anaesthesia is required, the choice of induction agents include
inhalational agents, thiopental, etomidate ( non-lipid
formulation) and ketamine.
 If tracheal intubation is required and a NMBA is

contraindicated:
o A remifentanil infusion, magnesium sulphate and

topical anaesthesia are helpful adjuncts to deep
anaesthesia in facilitating laryngoscopy and
intubation.
o Where remifentanil was used in the previous
anaesthetic, consider the use of alfentanil.
o Awake intubation under topical anaesthesia is an
alternative
 If local anaesthetics are not contraindicated, sufficient surgical

muscle relaxation can usually be provided if necessary with
adequate depth of anaesthesia and adjunct neuroaxial block,
transversus abdominis blocks, rectus sheath blocks or other
peripheral nerve block.
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 Pre-warn the theatre team beforehand, and be prepared to
diagnose and treat anaphylaxis promptly.
 Premedication with antihistamines and steroids may reduce

the severity of reactions caused by non-specific histamine
release but will not prevent anaphylaxis.
Avoid the following if administered/exposed during the 60 minutes

prior to the suspected anaphylactic event:
 All drugs to which the patient was exposed, with exception of

inhalational anaesthetist agents.
 All antibiotics of the same class that was administered (beta
lactams; macrolides; fluorquinolones; aminoglycosides;
monobactams; carbapenems). The surgical and anaesthetic
team should discuss antibiotic choice with a microbiologist.
 If an NMBA was administered during this period, all NMBAs
should be avoided unless it is impossible to do so, due to the
risk of cross-sensitivity.
 Chlorhexidine (including chlorhexidine, antiseptic wipes,
medical gel and chlorhexidine-coated intravascular
lines/catheters)
 IV colloids
 Radiological contract and dyes used for lymph node
identification
 Latex.
 Local anaesthetics of the same class.
 Histamine-releasing drugs (morphine and codeine) as the
previous reaction may have been due to non-specific
histamine release
If past anaesthetic records are not available, in addition to the

above:
 Assume that the patient previously received an antibiotic.

Antibiotics are the most common cause of perioperative
anaphylaxis in the UK. Discuss antibiotic prophylaxis with a
microbiologist beforehand.
 Assume that the patient was previously exposed to propofol,
morphine, chlorhexidine, latex, IV colloid and NMBA.
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The severity-grading of hypersensitivity reactions depends on signs

Grade 1: is characterized by cutaneous features such as rash, itch

Grade 2: mild hypotension or wheeze (usually not requiring

Grade 3: hypotension or wheeze are severe, and may include

Grade 4: fulfils the requirements for initiating cardiopulmonary

Grade 5: is a fatal reaction.

Perioperative anaphylaxis is a clinical diagnosis, and presenting

The guidance applies to all anaesthetists who are responsible for

3.Guideline Standards and Procedures

Anaphylaxis is likely when all the following criteria are met:

Sudden onset and rapid progression of symptoms

Life threatening Airway and/or Breathing and/or Circulation problems,

HYPOTENSION being the most frequent presenting feature

Skin and/or mucosal changes (flushing, urticarial, angioedema) are

Under Anaesthesia Common Signs include:

1-Adrenaline is the primary treatment of

3-If an IV colloid is being administered at the time of the

5-Vasopressin and glucagon for the management of

Details of locations are in RARE EMERGENCY DRUGS

9 -Chlorphenamine may be given as part of the resuscitation

11.-When anaphylaxis occurs following recent insertion of a

12-Patients with severe anaphylaxis should be admitted to critical

13-All patients with suspected anaphylaxis should be closely

14-Non-essential surgery should not be started after severe

15-Where pulse oximeter saturations fall during anaphylaxis in a

16-Latex related anaphylaxis – atypical late presentation often

17-If an adverse reaction to blood or blood components is

-All cases of severe perioperative anaphylaxis, including

-All cases of Grades 3–5 perioperative anaphylaxis should be

-Operating theatres should have an accessible list of chlorhexidine-

-If administration of Patent Blue dye is planned during surgery, the

-Investigation of perioperative anaphylaxis should include

Investigations and referral to Allergy Clinic.

ANAESTHETIC ANAPHYLAXIS INVESTIGATION BOX CHECKLIST

Boxes should be in Recovery areas, ICUs, Maternity Suite, MRI, CTscan

This pack contains:

MAST CELL TRYPTASE (Blood test) SENT TO IMMUNOLOGY AT

0 hours 1-2 hours 24hours

Brown (serum) Bottle: Labelled with times

 It is anaesthetist responsibility to ensure the samples are

 Ensure the event is reported to the MHRA though the Yellow

All patients experiencing suspected perioperative anaphylaxis should

Patients should be ideally seen by Allergy Clinic within 6 weeks.

1.-Document in Medical Notes

Glenfield Hospital Leicester 0116 287 1471

8.-Explain to patient and complete Patient Letter.

All anaesthetists responsible for perioperative care should be

5.-Monitoring and Audit Criteria

RCUK 2016: Emergency treatment of anaphylactic reactions:

MHRA 2012: All medical devices and medical products containing

-Anaesthesia, Surgery and Life-Threatening Allergic Reactions

- Australian and New Zealand College of Anaesthetists (ANZCA)

Anaesthetic anaphylaxis; perioperative anaphylaxis; suspected

Prea Ramasamy, Consultant

Details of Changes made during

…………………………………………………… Telephone ……………................……………...

Referring consultant anaesthetist (for clinic correspondence)

Telephone……………………………... Secure Email …………………………………………..