Suspected perioperative hypersensitivity reactions are rare but contribute significantly to the morbidity and mortality of surgical procedures. Recent publications have highlighted the differences ...between countries concerning the respective risk of different drugs, and changes in patterns of causal agents and the emergence of new allergens. This review summarises recent information on the epidemiology of perioperative hypersensitivity reactions, with specific consideration of differences between geographic areas for the most frequently involved offending agents.
Suspected perioperative allergic reactions are rare but can be life-threatening. The diagnosis is difficult to make in the perioperative setting, but prompt recognition and correct treatment is ...necessary to ensure a good outcome. A group of 26 international experts in perioperative allergy (anaesthesiologists, allergists, and immunologists) contributed to a modified Delphi consensus process, which covered areas such as differential diagnosis, management during and after anaphylaxis, allergy investigations, and plans for a subsequent anaesthetic. They were asked to rank the appropriateness of statements related to the immediate management of suspected perioperative allergic reactions. Statements were selected to represent areas where there is a lack of consensus in existing guidelines, such as dosing of epinephrine and fluids, the management of impending cardiac arrest, and reactions refractory to standard treatment. The results of the modified Delphi consensus process have been included in the recommendations on the management of suspected perioperative allergic reactions. This paper provides anaesthetists with an overview of relevant knowledge on the immediate and postoperative management of suspected perioperative allergic reactions based on current literature and expert opinion. In addition, it provides practical advice and recommendations in areas where consensus has been lacking in existing guidelines.
In this study, the authors designed checklists to guide care during operating-room crises and evaluated them in a simulated operating room. The availability of checklists improved adherence to best ...practices by operating-room teams during simulations of surgical crises.
Operating-room crises (e.g., massive hemorrhage and cardiac arrest) are high-risk, stressful events that require rapid and coordinated care in a time-critical setting. The reported incidence may be rare for an individual practitioner,
1
but the aggregate incidence for a hospital with 10,000 operations a year is estimated to be approximately 145 such events annually.
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These are situations in which the way the team cares for a patient will make the difference between life and death. Failure to effectively manage life-threatening complications in surgical patients has been recognized as the largest source of variation in surgical mortality among hospitals.
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Small-scale studies . . .
Endoscopy and Sedation Hepner, David L.; Siddiqui, Uzma D.
The American journal of gastroenterology,
10/2022, Letnik:
117, Številka:
10S
Journal Article
Recenzirano
Odprti dostop
Pregnancy results in progressive increases in oxygen consumption and minute ventilation along with a reduced back-up oxygen supply, which comes from decreased residual volume and functional residual ...capacity (1). Prompt treatment of hypotension is also very important because uteroplacental blood flow is not autoregulated, and a decrease in maternal blood pressure will ultimately cause a decrease in blood flow to the fetus. Red blood cell volume increases in response to the increased erythropoietin levels, which are also affected by hormonal changes in progesterone, prolactin, and placental lactogen. There is no correlation with race, body mass index, or weight gain during pregnancy (15).
Anesthesiologists use a myriad of drugs during the provision of an anesthetic. Many of these drugs have side effects that are dose related, and some lead to severe immune-mediated adverse reactions. ...Anaphylaxis is the most severe immune-mediated reaction; it generally occurs on reexposure to a specific antigen and requires the release of proinflammatory mediators. Anaphylactoid reactions occur through a direct non-immunoglobulin E-mediated release of mediators from mast cells or from complement activation. Muscle relaxants and latex account for most cases of anaphylaxis during the perioperative period. Symptoms may include all organ systems and present with bronchospasm and cardiovascular collapse in the most severe cases. Management of anaphylaxis includes discontinuation of the presumptive drug (or latex) and anesthetic, aggressive pulmonary and cardiovascular support, and epinephrine. Although a serum tryptase confirms the diagnosis of an anaphylactic reaction, the offending drug can be identified by skinprick, intradermal testing, or serologic testing. Prevention of recurrences is critical to avoid mortality and morbidity.
Background Because operating room crises are rare events, failure to adhere to critical management steps is common. We sought to develop and pilot a tool to improve adherence to lifesaving measures ...during operating room crises. Study Design We identified 12 of the most frequently occurring operating room crises and corresponding evidence-based metrics of essential care for each (46 total process measures). We developed checklists for each crisis based on a previously defined method, which included literature review, multidisciplinary expert consultation, and simulation. After development, 2 operating room teams (11 participants) were each exposed to 8 simulations with random assignment to checklist use or working from memory alone. Each team managed 4 simulations with a checklist available and 4 without. One of the primary outcomes measured through video review was failure to adhere to essential processes of care. Participants were surveyed for perceptions of checklist use and realism of the scenarios. Results Checklist use resulted in a 6-fold reduction in failure of adherence to critical steps in management for 8 scenarios with 2 pilot teams. These results held in multivariate analysis accounting for clustering within teams and adjusting for learning or fatigue effects (11 of 46 failures without the checklist vs 2 of 46 failures with the checklist; adjusted relative risk = 0.15, 95% CI, 0.04–0.60; p = 0.007). All participants rated the overall quality of the checklists and scenarios to be higher than average or excellent. Conclusions Checklist use can improve safety and management in operating room crises. These findings warrant broader evaluation, including in clinical settings.
Suspected perioperative allergic reactions are often severe. To avoid potentially life-threatening re-exposure to the culprit drug, establishing a firm diagnosis and identifying the culprit is ...crucial. Drug provocation tests are considered the gold standard in drug allergy investigation but have not been recommended in the investigation of perioperative allergy, mainly because of the pharmacological effects of drugs such as induction agents and neuromuscular blocking agents. Some specialised centres have reported benefits of provocation testing in perioperative allergy investigation, but the literature on the subject is limited. Here we provide a status update on the use of drug provocation testing in perioperative allergy, including its use in specific drug groups. This review is based on a literature search and experiences of the authors comprising anaesthesiologists and allergists with experience in perioperative allergy investigation. In addition, 19 participating centres in the International Suspected Perioperative Allergic Reaction Group were surveyed on the use of provocation testing in perioperative allergy investigation. A response was received from 13 centres in eight European countries, New Zealand, and the USA. Also, 21 centres from the Australian and New Zealand Anaesthetic Allergy Group were surveyed. Two centres performed provocation routinely and seven centres performed no provocations at all. Nearly half of the centres reported performing provocations with induction agents and neuromuscular blocking agents. Drug provocation testing is being used in perioperative allergy investigation in specialised centres, but collaborations between relevant specialties and multicentre studies are necessary to determine indications and establish common testing protocols.
Abstract Objective Identifying patient factors correlated with specific needs in preoperative decision making is of clinical and ethical importance. We examined patterns and predictors of ...deficiencies in informed surgical consent and shared decision-making in preoperative patients. Methods Validated measures were used to survey 1034 preoperative patients in the preoperative clinic after signed informed consent. Principal component analysis defined correlated groupings of factors. Multivariable analysis assessed patient factors associated with resultant groupings. Results 13% of patients exhibited deficits in their informed consent process; 33% exhibited other types of deficits. Informed consent deficits included not knowing the procedure being performed or risks and benefits. Other deficits included not having addressed patient values, preferences and goals. Non-English language and lower educational level were factors correlated with higher risk for deficits. Conclusion Deficits exist in over a third of patients undergoing preoperative decision-making. Sociodemographic factors such as language and educational level identified particularly vulnerable groups at risk for having an incomplete, and possibly ineffective, decision-making process. Practice implications Interventions to identify vulnerable groups and address patient centered surgical decision making in the pre-operative setting are needed. Focused interventions to address the needs of at-risk patients have potential to improve the surgical decision-making process and reduce disparities.
Simulation-based education is often highlighted as a method to prepare health personnel to handle clinical emergencies through repeated training and the design of supports. As one of the most common ...clinical emergencies in anaesthesia, anaphylaxis is often included in simulation scenarios at both graduate and postgraduate levels. Case reviews of anaphylaxis management continue to identify deficiencies in clinical responses. We evaluated the evidence to support the use of simulation to address these deficiencies. We undertook a comprehensive review of the MEDLINE and Embase databases with MESH terms ‘Anaphylaxis’, ‘Anaesthesia’, ‘Simulation training’, and variations of these terms. Articles were also searched from reference lists in the identified papers. A total of 39 articles on perioperative anaphylaxis simulation were identified, with most focusing on the clinical skills of individuals. However, anaphylaxis scenarios are also being used in assessment of teams and in the evaluation of broader system performance. Many countries mandate simulation training and competency assessment at graduate and postgraduate levels: despite this, none of the articles linked simulation training or assessment with improved patient management or outcomes. We found evidence that in situ simulation and use of cognitive aids lead to improved teamwork and task performace. Quantitative and qualitative evidence for simulation-based perioperative training is limited. Future studies should investigate whether simulation training in perioperative anaphylaxis, particularly in situ simulation, translates into improved patient management and outcomes.
There is no universal agreement on the definition of
anaphylaxis or the criteria for diagnosis. In July 2005, the National Institute of Allergy and Infectious Disease and Food Allergy and Anaphylaxis ...Network convened a second meeting on anaphylaxis, which included representatives from 16 different organizations or government bodies, including representatives from North America, Europe, and Australia, to continue working toward a universally accepted definition of anaphylaxis, establish clinical criteria that would accurately identify cases of anaphylaxis with high precision, further review the evidence on the most appropriate management of anaphylaxis, and outline the research needs in this area.
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