Anaphylaxis

Anphylactoid
Anaphylaxis shock
Allergic related conditions
 ANAPHYLAXIS

In a few seconds it was extremely ill;

breathing became distressful and panting;
it could scarcely drag itself along, lay on
its side, was seized with diarrhea, vomited
blood and died in twenty five minutes.

Charles Richet 1902

 Apakah anaphylaxis?
Reaksi akut allergi sistemik
Terkait dengan IgE
Sering terjadi karena obat, makanan, dan
sengatan serangga
Termasuk hipersensitivitas Type I
Ditandai dgg keterlibatan berbagai fungsi
organ ;
Cardiovasculair
Airway & breathing
Skin & GI Tract
 Sejarah
Pertama terekam 2640BC dalam
hieroglyphics
bee sting of a pharaoh
Richet & Portier
South Seas
Man-o-war
coined term anaphylaxis
 Epidemiology of Anaphylaxis
1-15% of US population (2.8 to 42.7 million
people) may be at risk (Yocum et al, Neugut et al)
30/100,000 population/year (Yocum et al)
Estimated annual incidence
21/100,000 (Yocum et al)
0.95% of 1.2 million individuals in a claims
database were dispensed injectable epinephrine
Rates ranged from 1.44% of patients <17 years old to
0.32% of patients >65 years
Incidence of anaphylaxis is increasing

Sheikh et al, BMJ, 2000; Yocum et al, J Allergy Clin Immunol, 1999; Simons et al, J Allergy Clin Immunol, 2002, Neugut et
al, Arch Int Med, 2001.
 anaphylactoid
reaksi anaphylaxis tp non-immunologi
gjl klinis
dose-dependent
anaphylaxis shock
shock akibat kolap sistem cardiovasculer pd
reaksi anafilaxis
allergic related condition
keadaan klinis akibat alergi mirip anafilaxis :
asthma, urtikaria , angioedema, dll
 Etiologi
sensitisasi terjd stlh exposure allergen
Food
Vaccines
Latex
Insect stings & bites
Pollens & non pollen extracts
Drugs :
Penyebab Anaphylaxis

www.emnet-usa.org
Drugs :
Antibiotika
NSAID
Kontras Radiologi
Insulin : bovine > porcine > human
Protamine
Anestesi lokal
Pelemas otot dan obat GA
 Manifestasi klinis
Respirasi ;
Upper : stridor ,hoarseness, wheezing insp, insp t
swollen ; lips, uvula,tongue
Lower : wheez exp, exp t, breath sounds
Tanda vital ; RR, oksigenasi & SaO2
Gejala : sesak, gelisah, kebiruan, batuk
Hemodynamic ; shock
Hipotensi, takhikardi s/d TTU & TTB
Signs : pallor, ekstrimitas dingin, pulsasi lemah,
mottling, capillary refill
EKG monitor : SVT aritmia, iskhemi/infark miokard
 Skin ;
Gejala ;Gatal, kemerahan
Sign ; urticaria, angioedema pd lips, neck, eye,
face, diaphoresis
GI T ;
Gejala ; mual / muntah, cramp & nyeri perut
Sign ; diare, emesis
Neuro ;
Gejala ; headache,dizziness, confusion
Sign ; syncope, delirium
Nasal ; sneezing, pruritus, rhinorrhea
Haematologi ; hemoconsentrasi , DIC
Tata laksana :
1. Primer / immediate
Singkirkan penyebab alergi
Call for HELP ( activate blue code )
Jaga jalan napas tetap bebas
Oksigenasi high flow dg masker 10 lpm
Head down
Posisi syok
epinephrine / adrenaline
injeksi IM / SC
berikan 0,3 0,5 mg ( 1 : 1000 ) ulang bila perlu 10
15 mnt . Bisa lewat Endotracheal tube kalau
sudah terpasang
Pasang infus diameter terbesar yg bisa masuk
berikan koloid / kristaloid 20 40 cc / kgBB/grojok
 ANGKAT
KEDUA
TUNGKAI

Posisi shock

naik
2. Sekunder
Bila bronkhospasme tdk membaik stlh
adrenalin
berikan salbutamol dg dosis
Loading 250 microgram / iv
Maintenance 5 20 microgram / mnt
Atau aminophyllin 6-8 mg/kgBB selama 20 mnt
Bronkhospasme disertai shock
Hidrocortisone 300 mg/iv atau methylprednisolone
2 g/iv
Bila msh shock , infus / grojok cairan
Infusi inotropik / cathecolamine ; (dopamin,
norepinephrine)
 Adrenalin 5mg/500 cc cairan ( 10 mcg/ml ) berikan
10 85 cc/jam
Noradrenalin 4mg/500 cc cairan ( 8 mcg/ml )
berikan 25 100 cc/jam
Dopamine 5 15 mcg/KgBB/mnt
Antihistamine ; chlorpheniramine 20 mg
encerkan/ iv pelan
Obat2 an lain;
H1 blocker diphenhydramine 50 mg / iv
H2 blocker ranitidine 50 mg / iv
Bila tlh lbh 20 mnt perbaikan tdk adequat boleh
diberikan Nabic 1 2 mEq/kgBB/bolus
Pencegahan
hindari penggunaan agent penyebab sesuai
anamnesa
Desentisasi
Desensitisasi alergi adalah suatu bentuk
terapi dimana allergen-alergen diinjeksikan
pada pasien dengan tujuan mengurangi atau
menghilangkan respon alergi. Ini juga disebut
imunoterapi allergen, hiposensitisasi atau terapi
injeksi alergi.
Gunakan radiokontras dg osmolaritas rendah
PENCEGAHAN
Bila tidak mungkin dihindari berikan ;
Berikan korticosteroid dan H1 blocker
Bila perlu ephedrine
Test diagnostik
 Komplikasi :
1. Respirasi : resp arrest, aspirasi, edema paru
2. CV : shock, MI, MOF.
3. Neuro : syncope, seizures,delirium
4. Kulit : sekunder infeksi
 Anaphylaxis di anestesi
Anaphylaxis selama anestesi adalah suatu
fenomena langka , tetapi dapat mengancam jiwa bila
terjadi dan bila tidak dikelola dengan benar .
Angka Kejadian di dunia akibat reaksi alergi selama
anesthesia adalah 1 : 3500 ( Kanada ) , 1 : 6000
( Norwegia ) , 1 : 10000 sampai 1: 20000
( Australia ) dan 1 : 34.000 8 ( pusat tunggal , USA )
, dan memiliki tingkat kematian 3,5 % sampai 10 %
Alergi bisa terjadi karena memakai muscle relaxant,
dan antibiotika
What impedes diagnosis under anaesthesia..?
1. Patient is draped - masks skin rashes. Therefore respiratory system and
cardiovascular system signs may be better indicators.
2. Anaesthetic drugs alter vasoactive mediators release, delaying possible
early recognition of anaphylaxis.
3. Some anaesthetic drugs (eg: propofol) mimic vasodilatation by causing
hypotension.
4. Scenarios which may mimic anaphylaxis are:
a. pulmonary embolism
b. myocardial infarction
c. aspiration
d. vasovagal reaction
 Pencegahan
Anamnesa riwayat alergi atau riwayat
penyakit dahulu
Bila didapatkan Riwayat alergi makanan,
asma, pasien atopik; pasien yang memiliki
allergu terhadap lateks dan neuromuscular
blocking agen (NMBAs)
Sebaiknya dihindari
 Penyebab di Anestesi
NMBA (Neuromuscular Blocking Agent)
Succynilcholin (Paling
banyak),Benzylisoquinoliniums seperti
mivacurium and atracurium
Antibiotika (terbanyak golongsn Peniccilin)
Latex karet
Anestesi lokal
Opioids (Morphine)
Anaphylaxis & specific anaesthesia drugs.
Muscle Relaxants
Most common anaesthetic mediators of anaphylaxis.
Account for 69.2 % of anaphylactic reactions under anaesthesia.

Inciting factors are the 2 quaternary or tertiary ammonium ions.

Suxamethonium causes more commonly than NDMRs.

Primary exposure is explained by sensitisation to quaternary or tertiary

ammonium ions present in over the counter cosmetic preparations.
Neostigmine and morphine also contain ammonium ions which can
cross react with muscle relaxants.
Anaphylaxis & specific anaesthesia drugs.
Muscle Relaxantscontd..

Direct mast cell degranulation is mediated by D-tc,

atracurium, cisatracurium, doxacurium and mivacurium.

Increased incidence of anaphylactic reactions and deaths with

use of rocuronium warrant further study.

Radioimmunoassay and skin challenge tests can help

avoid these reactions.
Anaphylaxis & specific anaesthesia drugs.
Muscle Relaxantscontd..

Muscle Relaxants Incidence

Rocuronium 98%
Suxamethonium 78%
Atracurium 71%
Vecuronium 59%
Pancuronium 20%
Mivacurium 9%
Cisatracurium 1%
Anaphylaxis & specific anaesthesia drugs.
Opoids.
Anaphylactic reactions are rare.
Morphine and meperidine most commonly implicated.
Fentanyl is deemed to be the safest.

Barbiturates.
Incidence of anaphylactic reactions with thiopental is 1 in 30, 000.
Best detected by detection of IgE antibodies by RAST method.
Propofol.
Incidence of anaphylactic reactions with propofol is 1 in 60, 000.
Reaction may be due to egg lecithin component of propofol.
But overall, propofol is not contraindicated in egg allergy patients
Anaphylaxis & specific anaesthesia drugs.
Other induction agents.
Etomidate is the most immunologically safe induction agent.
Next is ketamine.

Benzodiazepines.
Very rare
More likely with diazepam.

Volatile anaesthetics.
No reports of anaphylaxis have been reported.
However immune mediated hepatic injury (halothane) can present as
rash, fever, arthralgias, eosinophilia and increased liver enzymes.
Anaphylaxis & specific anaesthesia drugs.
Aprotinin.
Derived from bovine lung, antigenic in humans.
Reactions are more common if administered within 6 months of primary
exposure.
Seen in cardiac surgeries

Heparin.
Derived from bovine or porcine lung.
Antigenic in humans.
Reactions are in the form of heparin induced thrombocytopenia (HIT)
HIT is less common with LMWH.
Anaphylaxis & specific anaesthesia drugs.
Protamine Sulfate.
Derived from salmon sperm.
Used to reverse anticoagulant effect of heparin.
Reactions are more common in patients who have received insulin
preparations containing protamine-zinc.
Urticaria, systemic hypotension with pulmonary vasoconstriction

Antibiotics.
Penicillins, cephalosporins and -lactam antibiotics
Vancomycin (red man syndrome), bacitracin
Clindamycin, metronidazole, gentamicin
Anaphylaxis & specific anaesthesia drugs.
Other agents.

Povidone-Iodine
Iodinated contrast material
Chlorhexidine.
Latex.
Colloids. ( albumin, dextran, hetastarch and gelatin)
Isosulfan blue dye.
Gejala klinis
 Penatalaksanaan
manajemen terdiri dari tiga tindakan yang
berbeda:
i)Penghentian
substansi obat penyebab,
ii) meniadakan efek dari mediator terhadap
presentasi antigen, dan
iii) mencegah pelepasan mediator lanjutan
Penatalaksanaan
In Summary.

Anaphylactic reactions can occur with just about any of the day to day
preparations used in the OR
Early recognition of signs & symptoms and prompt management alter
the outcome successfully.
Prevention is always preferred.
For prevention to be effective, prior detection is essential.
Meticulous history, skin allergy testing and perioperative preparedness
can make the difference.
 Terima kasih