The Challenges of Perioperative Anaphylaxis

Perioperative anaphylaxis rare, approximately 1:10,000 anesthetic events in adults and 1:35,000 in children; but allergists/immunologists in a consultative practice are likely to encounter this problem more than once during their career. In addition to rare occurrence, many factors contribute to the challenges of assessing potential perioperative anaphylaxis: 1)the numerous possible explanations for hypotension or respiratory symptoms during anesthesia; 2) the limitations of drug allergy testing, without validated testing other than for penicillin; 3) the multiple drugs and agents used in anesthesia and surgery; 4) the challenges of communication between the anesthesia and surgical teams and outpatient specialists; 5) unfamiliarity of the allergist/immunologist with many of the medications used during anesthesia; and 6) the difficulties in acquiring the anesthetic drugs for testing. Furthermore, there is often time pressure due to the need to complete a surgical procedure. Hospital-based or large health care system-based allergists/immunologists have an advantage in access to anesthetic drugs for testing and usually have more open communication with the anesthesiologist, so a community allergist/immunologist may prefer to refer the patient. However, a process exists that, if followed by allergists/immunologists in a community or academic practice setting, provides reassurance and a path to repeat safe anesthesia. This article summarizes recent literature on perioperative anaphylaxis and provides guidance on this process.