Hypersensitivity, Immediate Clinical Trial
Official title:
Clinical Determinants in Perioperative Allergic Immediate Hypersensitivity
The clinical presentation of perioperative allergic and non-allergic clinical reactions is
often considered undistinguishable while the accurate analysis of clinical cases shows
striking clinical differences which might be predictive of the etiological diagnosis
(allergic versus non-allergic).
The four-step Ring and Messmer clinical scale helps to guide acute management of immediate
hypersensitivity accordingly to the clinical presentation although this scale does not take
into account the mechanism involved (i.e. allergic versus non-allergic). Non-allergic
clinical reactions are usually non-life-threatening and may, sometimes, spontaneously resolve
in contrast to allergic reactions which are mainly severe and life-threatening conditions,
typically called anaphylaxis.
The cornerstones of anaphylaxis management are fluid therapy and epinephrine. However, poor
outcome has been reported as a result of delayed treatment and/or inappropriate management of
perioperative anaphylaxis.
The main objectives of this study are to: i) characterize the clinical and paraclinical
determinants of IgE-mediated allergy that could be correlated to the ultimate diagnosis; and
ii) elaborate a decision-making algorithm for clinical patterns identification of
perioperative allergic reactions to guide acute management, thus potentially decreasing the
related morbidity and mortality.
The secondary objectives are to: i) suggest a modification of the Ring and Messmer scale
according to the phenotypes involved; ii) identify the clinical characteristics of isolated
non-allergic bronchospasm; iii) compare the most frequent agents involved in perioperative
IgE-mediated allergy to those reported in the international studies; iv) identify the
negative predictive values of skin tests in allergic and non-allergic patients; v) compare
the therapeutic modalities used to those recommended in the literature; vi) describe the
cases of morbidity and mortality and identify the potential risk factors.
The Ring and Messmer scale is used to quote the clinical features occurring in drug- or
latex-induced immediate hypersensitivity and has been adapted to the perioperative setting as
follows:
Grade I: Muco-cutaneous signs only (generalized erythema and/or extensive urticaria and/or
angioedema) Grade II: Mucocutaneous signs, hypotension, tachycardia and/or moderate
bronchospasm Grade III: Mucocutaneous signs, cardiovascular collapse, tachycardia or
bradycardia, bronchospasm, digestive signs Grade IV: Cardiac arrest Grade V: Death
Perioperative immediate hypersensitivity reaction requires further allergologic assessment.
The allergologic assessment is performed a few weeks after the reaction to confirm or
disprove an allergic mechanism behind the reaction (i.e. allergy versus non-allergy), and to
identify culprit agent(s) and safe drugs, including suitable alternatives. It is based on the
review of the details of the reaction along with histamine and/or tryptase levels and
specific Immunoglobulin E levels (when available) and skin tests results.
Plasma histamine and/or tryptase levels and Immunoglobulin E levels are measured at the time
of the reaction. Acute tryptase levels are compared to baseline tryptase measured at least 24
hours after the reaction or when the patient is referred for allergological investigation.
Skin tests, including prick-tests and intradermal tests, are performed during the
allergological assessment.
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