Tacquard Charles, Laroche Dominique, Stenger Rodolphe, Mariotte Delphine, Uring-Lambert Béatrice, De Blay Frédéric, Malinovsky Jean-Marc, Mertes Paul Michel
Hôpitaux universitaires de Strasbourg, département d'anesthésie-réanimation, 67000 Strasbourg, France.
CHU de Caen, laboratoire d'hormonologie, 14000 Caen, France.
Presse Med. 2016 Sep;45(9):784-90. doi: 10.1016/j.lpm.2016.05.016. Epub 2016 Jun 30.
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.
围手术期过敏反应的诊断基于与提示性时间线相关的临床特征、排除其他诊断、脱颗粒标志物（组胺、类胰蛋白酶）浓度升高以及过敏评估阳性（皮肤试验、特异性IgE）。在开始适当治疗后，麻醉医生应在反应发生后立即采集血样以测量组胺和类胰蛋白酶浓度，并在1 - 2小时后重复测量以验证速发型超敏反应的诊断。延迟测量基础类胰蛋白酶有助于排除肥大细胞增多症并解释中等水平的类胰蛋白酶。麻醉医生必须告知患者反应情况以获得其配合及对后续检查的同意，并必须记录反应时间、采血时间、可能的致病因素以及所给予的治疗。这些数据必须与实验室和过敏症专科医生共享。必须提交药物不良反应报告。过敏评估的金标准是皮肤试验。这些试验应在适当的机构进行，由经验丰富的人员操作，并符合现行指南。当临床特征与皮肤试验结果不一致时，特异性IgE检测和细胞检测可能会有所帮助。有时需要进行激发试验。在过敏评估后，与麻醉医生合作确定后续麻醉的最安全方案。必须告知患者并让其携带过敏警示卡。
