Lessons Learned From Fatal and Near-Fatal Perioperative IgE-Mediated Anaphylaxis

Area of Science:

• Anesthesiology
• Immunology
• Critical Care Medicine

Background:

• Perioperative anaphylaxis (POA) is a severe IgE-mediated allergic reaction causing circulatory failure and anesthesia-related deaths.
• Early identification of POA is critical for patient survival.
• Previous research identified early cutaneous vasoconstriction as a potential marker for IgE-mediated anaphylaxis.

Purpose of the Study:

• To determine if the early cutaneous vasoconstriction phenotype in POA increases the risk of fatal or near-fatal outcomes.
• To analyze the underlying mechanisms contributing to poor outcomes in POA patients with this phenotype.

Main Methods:

• Retrospective observational cohort study at two academic medical centers.
• Included adults diagnosed with IgE-mediated anaphylaxis (grades III-IV).
• Defined near-fatal POA as cases successfully treated with mechanical circulatory support.

Main Results:

• Of 72 patients, 27 (37.5%) exhibited early cutaneous vasoconstriction, while 45 (62.5%) had other cutaneous signs.
• All six fatal or near-fatal POA cases occurred in the early cutaneous vasoconstriction group (22.2% incidence).
• Early cutaneous vasoconstriction was consistently associated with bradycardia in severe cases, suggesting profound hypovolemia.

Conclusions:

• Perioperative anaphylaxis with early cutaneous vasoconstriction is associated with a significantly increased risk of fatal or near-fatal outcomes.
• This phenotype, along with bradycardia, may indicate greater initial severity due to hypovolemia.
• Recognizing this underappreciated phenotype is vital for timely and effective management of severe POA.