Special Considerations in the Perioperative Environment for Registered Nurses

Anaphylaxis

Anaphylaxis during surgery can be divided into non-allergic hypersensitivity which is estimated to occur in one in every 11,000 cases, and allergic reaction which is estimated to occur in one in every 10,000 cases. Of the anaphylaxis cases that do occur, the mortality rate is estimated to be between 3.8-4% because of close monitoring of patients.

(Dewachter & Savic, 2019)

Causes of Anaphylaxis in the Perioperative Environment

Common causes of anaphylaxis include:

  1. Anesthetic drugs such as antibiotics, IV anesthetics such as propofol, muscle relaxants such as succinylcholine.
  2. Dyes such as patent blue, methylene blue.
  3. Surgical prep such as chlorhexidine, povidone iodine.

Less common causes these days include latex, opioids, and local anesthetics.

(Dewachter & Savic, 2019)

Manifestations of Anaphylaxis in the Perioperative Setting

Most often, perioperative anaphylaxis occurs quickly after induction of anesthesia. Signs to watch for include:

  1. Hypotension due to systemic vasodilation.
  2. Erythema (rash) and or urticaria (hives).
  3. Edema especially around the face – swelling of eyes, tongue.
  4. Tachycardia initially, then bradycardia — or the patient may just present with bradycardia.
  5. Bronchospasm especially in those with reactive airways.

If not addressed quickly, these signs can lead to cardiovascular collapse and cardiac arrest.

(Dewachter & Savic, 2019)

Treatment of Anaphylaxis in the Perioperative Setting
  1. Stop using the suspected agent.
  2. Stop or lighten the anesthetic while resuscitating.
  3. Use Trendellenberg positioning or raise the patient’s legs.
  4. Call for help.
  5. Use IV fluids to restore intravascular volume.
  6. Ensure that the airway and ventilation are maintained.
  7. Give Epinephrine.
  8. Use B2 agonist (salbutamol) for bronchospasm.

The decision to proceed with the surgery or wake the patient and cancel must be determined by the perioperative team on a case-by-case basis. This depends on the severity of the anaphylactic reaction, the urgency of the surgery for the patient, and any underlying comorbidities. The patient may require additional monitoring postoperatively as well as follow up assessments and allergy testing.

(Dewachter & Savic, 2019)