P295

1
Skin Prick Testing Helps Discern the Cause of
Intra-Operative Anaphylaxis Allison Norton MD1,
Jayant K. Deshpande, MD, MPH2 Donna S. Hummell
MD3 Vanderbilt University Department of
Pediatrics1, Division of Pediatric Critical Care
Medicine 2, Division of Allergy Immunology and
Rheumatology3, Nashville, TN
P295 ACAAI 2006
All other tests were negative by standard
criteria of requiring gt 3 mm wheal over saline
for skin prick and gt 5 mm wheal over saline for
intradermal tests. It was recommended that if
any of these agents were to be used in the
future, they should be be administered separately
with 10 minutes between each drug.
RATIONALE
CASE STUDY (CONT.)
ANESTHETIC ANAPHYLAXIS
Neuromuscular blocking drugs (NMBD) are the most
common cause of anesthetic anaphylaxis. It is
important for allergists to know more about
anesthetic anaphylaxis and the role of skin prick
testing. A 6 year old presented for an elective
herniorrhaphy. During induction, he developed
hypotension, tachycardia and flushing. Immediatel
y prior to the event, he received vecuronium,
atropine, propofol, midazolam, and
fentanyl. Latex gloves were worn during the
procedure. He responded to aggressive fluid
resuscitation with dexamethasone, epinephrine and
diphenhydramine. Two months after this event,
the patient had skin prick testing and specific
IgE testing. Skin prick testing using 110
dilutions of standard concentrations of fentanyl,
atropine, propofol, vecuronium, cistracurium,
pancuronium were done. With the exception of
vecuronium, intradermal testing was done to the
above medications. Specific IgE testing was sent
for latex and found to be negative. Skin prick
testing to vecuronium was unequivocally positive
(wheal gt 3mm over saline prick test).

• Possible risk factors female sex (41), previous
  anesthetic
• anaphylactic reactions patients with atopy,
  allergy and
• asthma.
• 40 of patients who have anaphylaxis during
  anesthesia
• have a history of allergy and atopy.
• Patients who have true clinical manifestations of
• anaphylaxis during anesthesia have
• 1. 85-90 incidence of positive skin test to a
  drug administered within 10 minutes of the
  reaction.
• 60-90 incidence of IgE antibodies to a drug
  used during anesthesia if they have a positive
  skin test.
• 94-96 incidence of positive skin testing if
  there is elevated tryptase levels.

CASE STUDY
Pre- medication with diphenhydramine and
steroids were also recommended. The patient
underwent surgery 3 months later without
incident. He was pre-medicated prior to
surgery. Fentanyl and propofol was used for
anesthesia. No neuromuscular blockers were
given.

Vecuronium 5 mm wheal and 25 mm of erythema
DISCUSSION
Skin prick testing is a safe and appropriate
means to determine the cause of pre-operative
anaphylaxis. However, caution should be used
when interpreting a negative skin prick test,
particularly when the history is convincing for
allergy. If a NMBD is suspected, one should
recommend avoiding all NMBDs because of the
possibility of cross reactivity.
ANESTHETIC ANAPHYLAXIS
The true incidence of anaphylaxis to anesthetic
agents is unknown. However estimates fall
between 1 900 to 122,000. Mortality is 4 and
an additional 2 patients experience brain
damage. Neuromuscular blocking drugs (NMBD) are
responsible for 61.6 of cases of anesthetic
anaphylaxis. Reactions to induction agents,
blood volume replacement solutions, latex, and
antibiotics comprise most of the remainder of the
reaction. Since all NMBDs share a tertiary and
quaternary ammonium, cross reactivity is common.

REFERENCES
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Sensitivity to Rocuronium and Vecuronium A
Randomized Controlled Prick-Testing Study in
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Anaphylactic Reactions to Anaesthetic Drugs..
Drug Safety 2004 27(6) 393-410. Harboe T,
Gutormsen AB, Irgens A, Dybendal T, Florvaag E.
Anaphylaxis During Anesthesia in Norway.
Anesthesiology 2005 102 897-903. Matthey P,
Wang P, Finnegan BA, Donnelly M. Rocuronium
Anaphylaxis and Multiple Neuromuscular Blocking
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