title: Comprehensive allergy evaluation is useful in the subsequent care of patients with drug hypersensitivity reactions during anesthesia.
abstract: BACKGROUND
  For patients with a history of drug hypersensitivity reaction (HSR) during anesthesia, strategies to minimize risk with subsequent anesthesia are unclear. Identification of the cause of HSR during anesthesia remains challenging.
  
  
  OBJECTIVE
  To determine the success of a comprehensive allergy evaluation and management plan for patients with HSR during anesthesia, including identification of the causative agent and review of outcomes during subsequent anesthesia exposure.
  
  
  METHODS
  We performed chart reviews of patients referred for the evaluation of HSR during anesthesia between 2003 and 2012. Data collection included patient characteristics, signs/symptoms of HSR during anesthesia, and subsequent outcomes. Patients underwent comprehensive allergy evaluation including skin testing for identifying potential culprit agents, and the results were used to provide recommendations for any subsequent anesthesia.
  
  
  RESULTS
  Over the 10-year study period, 73 patients with HSR during anesthesia were referred for further evaluation. Thirteen patients (18%) had positive skin test results to a drug received during anesthesia. One patient with a positive skin test result was diagnosed with mastocytosis. The causative agents identified in these 13 patients included latex, β-lactam antibiotics, neuromuscular blockers, tetracaine, odansetron, and fentanyl. On follow-up, 47 of the 73 patients (64%) subsequently underwent procedures requiring anesthesia. Using our recommendations from evaluation and testing, 45 of these 47 patients (96%) successfully tolerated subsequent anesthesia. The 2 patients who developed recurrent HSR during anesthesia were later diagnosed with mast cell disorders.
  
  
  CONCLUSIONS
  Our comprehensive evaluation and management plan minimizes risk with subsequent anesthesia even when the cause of HSR could not be identified. Baseline tryptase levels may be helpful in this patient population to diagnose mast cell disorders.
authors.affiliation: Division of Allergy and Inflammation, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA. Electronic address: aguyer@bidmc.harvard.edu.
authors.forename: Autumn C
authors.initials: AC
authors.lastname: Guyer
authors.affiliation: Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
authors.forename: Rebecca R
authors.initials: RR
authors.lastname: Saff
authors.affiliation: Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
authors.forename: Michelle
authors.initials: M
authors.lastname: Conroy
authors.affiliation: Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
authors.forename: Kimberly G
authors.initials: KG
authors.lastname: Blumenthal
authors.affiliation: Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
authors.forename: Carlos A
authors.initials: CA
authors.lastname: Camargo
authors.affiliation: Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
authors.forename: Aidan A
authors.initials: AA
authors.lastname: Long
authors.affiliation: Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
authors.forename: Aleena
authors.initials: A
authors.lastname: Banerji
mesh_terms: D000758:Anesthesia / Q000009:adverse effects*; D004342:Drug Hypersensitivity / Q000175:diagnosis* / Q000276:immunology*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012882:Skin Tests / Q000706:statistics & numerical data*
keywords: Allergic reactions during anesthesia; Drug allergy; Drug hypersensitivity reaction; General anesthetics; Hypersensitivity reactions during anesthesia; Intraoperative anaphylaxis; Perioperative anaphylaxis; Tryptase