Guidelines from NHS Lothian

Anaphylaxis @ RIE

Emergency management of suspected anaphylaxis In Theatre

Immediate Actions

Call for help

Communicate problem to theatre team

Send for Anaphylaxis management box and Cardiac Arrest trolley

Cease all likely triggers

CPR indicated if Systolic BP < 50mmHg or cardiac arrest



Signs during anaesthesia include:

  • Cardiovascular collapse
    • Unexplained tachycardia or bradycardia
    • Unexplained hypotension
  • Bronchospasm
  • Erythema
  • Urticaria
  • Hypotension
  • Angioedema
  • Hypoxia
  • Cutaneous rash
Additional detail

Delegate timekeeping and monitoring roles

Consider chlorhexidine impregnated catheters as a possible cause


Airway

Ventilate with 100% Oxygen

Maintain airway and secure with ETT

Additional detail

Early endotracheal intubation warranted as may develop severe airway compromise secondary to angioedema

Use uncut ETT tube if significnat facial swelling developing


Breathing

Check :

  • Chest symmetry and Resp. rate
  • Breath sounds
  • SpO2
  • Measured VTex
  • ETCO2.
  • Feel the airway pressure using reservoir bag and APL valve <3 breaths.
Additional detail

Rule out endobronchial intubation

If isolated bronchospasm refer to Bronchospasm Guideline

Circulation

Ensure patent IV access

Elevate patients legs if there is hypotension

Give IV adrenaline (1mcg/kg ) bolus as necessary

  • IM dose 0.5mg
  • Consider adrenaline infusion if repeat boluses required

Give IV crystalloid bolus (20ml/kg)

Additional detail

Hypotension may be resistant and may require prolonged treatment

If no IV access, intraosseus dose same as IV

Insert an A-Line for monitoring and ABGs

Consider Vasopressin if hypotension remains resistant to treatment

Consider Glucagon in Beta-blocked patients unresponsive to Adrenaline

Depth/ Additional drug treatment

Ensure adequate depth of anaesthesia

Give Hydrocortisone 200mg slow IV bolus as soon as able

Give Chlorphenamine 10mg slow IV bolus


Additional detail

Do not delay administration of hydrocortisone

Summary of Drugs used within this guideline

See below for summary of doses for drugs used in this Emergency Guideline

Additional detail

Adrenaline:

  • 1mcg/kg IV bolus repeat as neccsarry
  • 0.5mg IM adrenaline
  • IV Infusion 0.1mcg/kg/min
    • Note with 3mg Adrenaline in 50ml 5% glucose, rate in ml/hr = mcg/min
    • Therefore commence at 6mls/hr for a 60kg Adult

Glucagon 1mg IV repeated as necessary

Vasopressin:

  • 2 Units IV repeated as necessary
  • IV Infusion
    • 20 Units in 50ml 5% glucose, 0.4 Units/ml
    • Infuse at 0-6ml/hr

Hydrocortisone 200mg slow IV

Further Management steps to consider

Inform Critical Care

Take blood smaple for serum tryptase as soon as feasible

Additional detail

Take 5-10ml clotted blood for serum tryptase

Ensure subsequent serum tryptase testing as per NHS Lothian guideline

Liaise with department anaphylaxis lead regarding referral to a specialist allergy or immunology centre to identify the causative agent

Inform the patient, surgeon and GP

Report to MHRA

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