Intraoperative Anaphylaxis - Guidelines for Crises in Anaesthesia

• Unexplained hypotension

• Unexplained bronchospasm (wheeze may be absent if severe)

• Unexplained tachycardia or bradycardia

• Angioedema (often absent in severe cases)

• Unexpected cardiac arrest where other causes are excluded

• Cutaneous flushing in association with one of more of the signs above (often absent in severe cases)



❶ Call for help. Note the time. Stop or do not start non-essential surgery.

❷ Call for cardiac arrest trolley, anaphylaxis treatment pack and investigation pack.

❸ Remove all potential causative agents and maintain anaesthesia.

 • Important culprits: antibiotics, neuromuscular blocking agents, patent blue.

 • Consider chlorhexidine as cause (impregnated catheters, lubricants, cleansing agents).

 • Consider i.v. colloids as a possible cause.

 • Change to inhalational anaesthetic agent (if not already).

❹ Give 100% oxygen and ensure adequate ventilation:

 • Maintain the airway and, if necessary, secure it with tracheal tube.

❺ Elevate patient’s legs if there is hypotension.

❻ If systolic blood pressure < 50 mmHg or cardiac arrest, start CPR immediately.

❼ Give drugs to treat hypotension (Box A):

 • Hypotension may be resistant and may require prolonged treatment.

 • Give adrenaline bolus and repeat as necessary.

 • Consider starting an adrenaline infusion after three boluses.

 • If hypotension resistant, give alternate vasopressor (e.g. metaraminol, noradrenaline infusion +/ vasopressin)

 • Give glucagon in ß-blocked patient unresponsive to adrenaline.

❽ Give rapid i.v. crystalloid: 20 ml.kg-1 initial bolus, repeated until hypotension resolved.

❾ Give hydrocortisone as part of resuscitation (Box B).

❿ If bronchospasm is persistent, consider → 3-4

⓫ Take 5-10 ml clotted blood sample for serum tryptase as soon as patient is stable.

 • Plan for repeat sample at 1-2 hours and >24 hours.

⓬ Give chlorphenamine when feasible (Box B).

⓭ Plan transfer of the patient to an appropriate critical care area. Note tasks in Box D.

⓮ Prevent re-administration of possible trigger agents (allergy band, annotate notes/drug chart)



By Association of Anaesthetists @ https://twitter.com/AAGBI

Quick Reference Handbook - Guidelines for crises in anaesthesia 



#Anaphylaxis #Anesthesiology #Anesthesia #Intraoperative #Checklist #Diagnosis #Management #Workup