title: Diagnostic procedure after an immediate hypersensitivity reaction in the operating room.
abstract: The diagnosis of a perioperative allergic reaction is based on clinical features associated with a suggestive timeline, the exclusion of other diagnoses, elevated concentrations of degranulation markers (histamine, tryptase), and positive allergy assessments (skin tests, specific IgE). After initiating appropriate treatment, the anesthesiologist should take blood samples to measure histamine and tryptase concentrations just after the reaction and repeat them 1-2hours later to validate the diagnosis of immediate hypersensitivity. A delayed measurement of basal tryptase is useful to rule out mastocytosis and to interpret moderate tryptase levels. The anesthesiologist must inform the patient of the reaction to obtain adhesion and consent to subsequent investigations and must record the timing of the reaction and of the blood sampling, the possible causal agents, and the treatment administered. These data must be shared with the laboratory and the allergist. An adverse drug reaction report must be filed. The gold standard for allergy assessment is skin testing. These tests should be done in an appropriate facility, with experienced staff and in compliance with current guidelines. Specific IgE assays and cellular assays can help when clinical features and skin tests are discordant. Provocation tests are sometimes required. After allergy assessment, the safest protocol for subsequent anesthesia is determined in collaboration with the anesthesiologist. The patient must be informed and carry an allergy alert card.
authors.affiliation: Hôpitaux universitaires de Strasbourg, département d'anesthésie-réanimation, 67000 Strasbourg, France. Electronic address: charles.tacquard@gmail.com.
authors.forename: Charles
authors.initials: C
authors.lastname: Tacquard
authors.affiliation: CHU de Caen, laboratoire d'hormonologie, 14000 Caen, France.
authors.forename: Dominique
authors.initials: D
authors.lastname: Laroche
authors.affiliation: Hôpitaux universitaires de Strasbourg, université de Strasbourg, pôle de pathologie thoracique, fédération de médecine translationnelle, 67000 Strasbourg, France.
authors.forename: Rodolphe
authors.initials: R
authors.lastname: Stenger
authors.affiliation: CHU de Caen, laboratoire d'immunologie, 14000 Caen, France.
authors.forename: Delphine
authors.initials: D
authors.lastname: Mariotte
authors.affiliation: Hôpitaux universitaires de Strasbourg, laboratoire central d'immunologie, 67000 Strasbourg, France.
authors.forename: Béatrice
authors.initials: B
authors.lastname: Uring-Lambert
authors.affiliation: Hôpitaux universitaires de Strasbourg, université de Strasbourg, pôle de pathologie thoracique, fédération de médecine translationnelle, 67000 Strasbourg, France.
authors.forename: Frédéric
authors.initials: F
authors.lastname: De Blay
authors.affiliation: CHU de Reims, hôpital Maison-Blanche, département d'anesthésie-réanimation, 51100 Reims, France.
authors.forename: Jean-Marc
authors.initials: JM
authors.lastname: Malinovsky
authors.affiliation: Hôpitaux universitaires de Strasbourg, département d'anesthésie-réanimation, 67000 Strasbourg, France.
authors.forename: Paul Michel
authors.initials: PM
authors.lastname: Mertes
mesh_terms: D003663:Decision Trees; D003955:Diagnostic Tests, Routine; D006801:Humans; D006969:Hypersensitivity, Immediate / Q000175:diagnosis*; D007431:Intraoperative Complications / Q000175:diagnosis*; D009873:Operating Rooms