Predictive value of allergy tests for neuromuscular blocking agents: tackling an unmet need
- 21 May 2014
- journal article
- research article
- Published by Wiley in Clinical & Experimental Allergy
- Vol. 44 (8), 1069-1075
- https://doi.org/10.1111/cea.12344
Abstract
Background Neuromuscular blocking agents (NMBAs) are a predominant cause of perioperative anaphylaxis in Europe. Diagnosis of NMBA allergy relies upon the careful review of the anaesthetic report complemented with skin tests. Additional diagnostic tests are quantification of specific IgE antibodies (sIgE) and basophil activation test (BAT). However, data on the predictive value of the skin tests, the BAT and the sIgE assays (drug‐specific and substituted ammonium structures) are limited or not available, mainly because such exploration requires dangerous NMBA provocation tests. Methods In this study, the predictive value of skin test, BAT and measurement of sIgE to substituted ammonium structures is gathered from a review of anaesthetic records of subsequent surgical procedures with NMBA administration and/or occurrence of perioperative incidents. Results We investigated a series of 272 patients with perioperative anaphylaxis, of whom 100 had undergone second general anaesthesia. Negative skin test and negative BAT assisted the selection of alternative NMBA, which were well tolerated in all cases. Five patients with a positive sIgE to rocuronium but with negative skin testing and BAT safely received rocuronium during second anaesthesia. Twelve patients with sIgE reactivity to morphine, but negative skin test and BAT to benzylisoquinolines, tolerated administration of cisatracurium or atracurium. Alternatively, benzylisoquinoline allergy went undetected in the morphine solid‐phase assay. Conclusions Skin test and BAT have an excellent negative predictive value in our series. The uneventful re‐exposure of rocuronium in patients with an isolated positive sIgE result to rocuronium calls into question the predictive value of this assay and suggests sIgE serology to be less clinically predictive than the functional investigations relying upon activation of mast cells or basophils. The presence of a positive sIgE to substituted ammonium structures such as morphine does not preclude further use of benzylisoquinolines.Keywords
This publication has 22 references indexed in Scilit:
- Allergy to rocuronium: from clinical suspicion to correct diagnosisAllergy, 2011
- Evaluation of a New Routine Diagnostic Test for Immunoglobulin E Sensitization to Neuromuscular Blocking AgentsAnesthesiology, 2011
- On the origin and specificity of antibodies to neuromuscular blocking (muscle relaxant) drugs: an immunochemical perspectiveClinical & Experimental Allergy, 2009
- Basophil activation test by flow cytometry: Present and future applications in allergologyCytometry Part B: Clinical Cytometry, 2008
- Immunoglobulin E Antibodies to RocuroniumAnesthesiology, 2007
- Anaphylaxis during anaesthesia: diagnostic approachAllergy, 2007
- Flow‐assisted diagnostic management of anaphylaxis from rocuronium bromideAllergy, 2006
- Prevalence of IgE antibodies to morphine. Relation to the high and low incidences of NMBA anaphylaxis in Norway and Sweden, respectivelyActa Anaesthesiologica Scandinavica, 2005
- STUDIES ON THE MECHANISM OF MULTIPLE DRUG ALLERGIES. STRUCTURAL BASIS OF DRUG RECOGNITIONJournal of Immunoassay and Immunochemistry, 2001
- Anaphylaxis during induction of general anesthesia: Subsequent evaluation and managementJournal of Allergy and Clinical Immunology, 1990