Acknowledged experts have published in the most recent issue of Anaesthesia a guideline regarding 'Suspected Anaphylactic Reactions Associated with Anaesthesia' [1]. It presents a comprehensive update on the recent knowledge of anaphylaxis and anaesthesia. We agree with the recommendations concerning the immediate management. Still, we are astonished that vasopressin was not even mentioned as a second-line drug as it is the only substance – besides adrenaline - whose effectiveness in anaphylactic shock is supported by in-vitro and in-vivo data [2-5]. In profound vasodilatory shock maintaining perfusion of brain and heart is crucial. Under those circumstances time is often running against the patient. We are convinced that early administration of low doses of vasopressin to patients refractory to standard treatment is mandatory [5]. Here, in contrast to adrenaline, vasopressin augments systemic vascular resistance reliably [5]. We strongly recommend the integration of vasopressin as secondary management into the next guidelines.

W. Schummer                                                                                                                                                                                           Dep. for Anaesthesiology and Intensive Care Medicine
SRH Zentralklinikum Suhl, Germany

C. Schummer
Dep. for Anaesthesiology and Intensive Care Medicine
Friedrich-Schiller Universität Jena, Germany

References
1. Harper NJ, Dixon T, Dugué P, Edgar DM, Fay A, Gooi HC, Herriot R, Hopkins P, Hunter JM, Mirakian R, Pumphrey RS, Seneviratne SL, Walls AF, Williams P, Wildsmith JA, Wood P, Nasser AS, Powell RK, Mirakhur R, Soar J; Working Party of the Association of Anaesthetists of Great Britain and Ireland. Suspected anaphylactic reactions associated with anaesthesia. Anaesthesia 2009; 64: 199-211.
2. Bautista E, Simons FE, Simons KJ, Becker AB, Duke K, Tillett M, Kepron W, Mink SN. Epinephrine fails to hasten hemodynamic recovery in fully developed canine anaphylactic shock. International Archives of Allergy and Immunology 2002; 128: 151-64.
3. Dewachter P, Raëth-Fries I, Jouan-Hureaux V, Menu P, Vigneron C, Longrois D, Mertes PM. A comparison of epinephrine only, arginine vasopressin only, and epinephrine followed by arginine vasopressin on the survival rate in a rat model of anaphylactic shock. Anesthesiology 2007; 106: 977-83.
4. Dünser MW, Torgersen C, Wenzel V. Treatment of anaphylactic shock: where is the evidence? Anesthesia & Analgesia 2008; 107: 359-61.
5. Schummer C, Wirsing M, Schummer W. The pivotal role of vasopressin in refractory anaphylactic shock. Anesthesia & Analgesia 2008; 107: 620-4.