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Should surgery be proceeded or abandoned after intra-operative anaphylaxis?

Last post 13 Nov 2018, 3:10 AM by Paul Sadleir. 1 replies.
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  •  31 Oct 2018, 12:51 PM 2680

    Should surgery be proceeded or abandoned after intra-operative anaphylaxis?

    Sadleir et al. examined whether recovery outcomes were adversely affected by proceeding with the planned procedure after successful stabilisation of peri-operative anaphylaxis in 223 cases [1]. The authors recommended proceeding with surgery in patients with Grades 1, 2 and 3 hypersensitivity reactions, provided that continuing management of hypersensitivity will not hinder successful completion of surgery, or proceeding with the procedure would not impede re-institution of resuscitation when it is required. Although the findings in this study may provide significant insights into clinical practice, we would like to invite the authors to clarify some important issues.

    Firstly, the authors' use of the terms “major hypersensitivity-related complications” and “major hypersensitivity-related sequelae” may not be appropriate, because any complications or sequelae may result from hypersensitivity-related treatments rather than hypersensitivity per se. For instance, it has been well-documented that Takotsubo cardiomyopathy is related to catecholamine surge [2, 3] which may be part of the hypersensitivity treatment. However, the dosages of adrenaline in the two patients experiencing Takotsubo cardiomyopathy (both with Grade 4 hypersensitivity reactions) were not mentioned. Similarly, taking into account the relationship between intra-operative fluid administration and the development of acute respiratory distress syndrome (ARDS)[4], the link between intravenous fluid during hypersensitivity management under general anesthesia and the subsequent development of pulmonary complications (e.g. ARDS, prolonged ventilation) remains unclear from the authors' paper.

    Secondly, the authors suggest that once initial resuscitation had been achieved, continuing with planned surgery in patients with Grade 1, 2, and 3 hypersensitivity reactions was feasible. As objective criteria for successful resuscitation (i.e. stabilisation) of intraoperative anaphylaxis were not well defined, subjective clinical judgement may have determined whether or not to proceed with surgery. Furthermore, the majority of patients in that study were relatively healthy (80.7% ASA class 1 or 2) and younger (mean (SD) age 47 ± 18 years). Do the authors consider that their findings can therefore be extrapolated to patients with higher operative risk?

     

    C-K. Sun

    E-Da Hospital,

    Kaohsiung, Taiwan.

    K-C. Hung

    Chi Mei Medical Center,

    Tainan, Taiwan

    E-mail: ed102605@gmail.com


    No external funding and no conflicts of interest declared.

     

    References

    1. Sadleir PHM, Clarke RC, Bozic B, Platt PR. Consequences of proceeding with surgery after resuscitation from intra-operative anaphylaxis. Anaesthesia 2018; 73: 32-9.
    2. Pelliccia F, Kaski JC, Crea F, Camici PG. Pathophysiology of Takotsubo Syndrome. Circulation 2017; 135: 2426-41.
    3. Pelliccia F, Sinagra G, Elliott P, Parodi G, Basso C, Camici PG. Takotsubo is not a cardiomyopathy. International Journal of Cardiology 2018; 254: 250-3.
    4. Hughes CG, Weavind L, Banerjee A, Mercaldo ND, Schildcrout JS, Pandharipande PP. Intraoperative risk factors for acute respiratory distress syndrome in critically ill patients. Anesthesia and Analgesia 2010; 111: 464-7.
  •  13 Nov 2018, 3:10 AM 2689 in reply to 2680

    Should surgery be proceeded or abandoned after intra-operative anaphylaxis? A reply

    We thank Sun and Hung for their interest in our paper, which is the first to consider how to manage the factor that defines perioperative anaphylaxis: surgery itself [1]. Continuing with the planned procedure can theoretically influence either the natural course of anaphylaxis or attempts to effectively treat it, so we think it was entirely appropriate to consider a composite-outcome measure, including complications or sequelae that arose as a result of anaphylaxis or its subsequent treatment. As anaphylaxis will always be treated appropriately [2], we think that the source of adverse events is of little practical importance. All that is relevant to the question asked is whether patient outcomes are comparable between the cohort of patients in whom surgery proceeded and those in which it did not. 

    We observed that completing or abandoning surgery resulted in no clinically important difference in the rate of complications attributable to anaphylaxis or its management, in patients with major acute hypersensitivity reaction grades 1, 2 or 3. It was also evident from our research that surgery frequently proceeded, even though there are no objective criteria for successful resuscitation. The question of whether to proceed or not has never been considered by treatment algorithms, and there are no previously published guidance for clinicians, so we can only surmise that clinicians used subjective criteria to decide when to proceed with, or abandon, surgery. As our study has not detected an excess complication rate when either course is followed, we can only recommend that clinicians continue to use subjective - and the reason-based criteria outlined in our discussion – to decide if and when to continue with surgery.

    We observed that anaphylaxis occurred in younger, healthier patients, possibly related to age-related immunosenescence and the population age-distribution in Western Australia (median 36 years). We stated in our paper that ‘there are limits to… the applicability of this study to other populations', including those with higher operative risks, or surgical procedures not represented in our cohorts (vascular, neurosurgical or otorhinolaryngologic cases were present in small numbers in our study), and we recommend that clinicians need to repeat our work in these groups, with the aim of developing objective criteria for clinicians to follow when anaphylaxis occurs intra-operatively.

    P. Sadleir

    P. Platt

    R. Clarke

    B. Bozic

    Sir Charles Gairdner Hospital,

    Nedlands, Australia.

    Email: paul.sadleir@uwa.edu.au

     

    No external funding and no conflicts of interest declared.

     

    References

    1. Sadleir PHM, Clarke RC, Bozic B & Platt PR. Consequences of proceeding with surgery after resuscitation from intra-operative anaphylaxis. Anaesthesia 2018; 73: 32-9.
    2. Gibbs NM, Sadleir PHM, Clarke RC & Platt PR. Survival from perioperative anaphylaxis in Western Australia 2000-2009. British Journal of Anaesthesia 2013; 111: 589-93.
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