Institut Pasteur, Department of Immunology, Unit of Antibodies in Therapy and Pathology, Paris, France.
INSERM, U1222, Paris, France.
Br J Anaesth. 2017 Nov 1;119(5):908-917. doi: 10.1093/bja/aex260.
Prompt diagnosis of intra-anaesthetic acute hypersensitivity reactions (AHR) is challenging because of the possible absence and/or difficulty in detecting the usual clinical signs and because of the higher prevalence of alternative diagnoses. Delayed epinephrine administration during AHR, because of incorrect/delayed diagnosis, can be associated with poor prognosis. Low end-tidal CO2 (etCO2) is known to be linked to low cardiac output. Yet, its clinical utility during suspected intra-anaesthetic AHR is not well documented.
Clinical data from the 86 patients of the Neutrophil Activation in Systemic Anaphylaxis (NASA) multicentre study were analysed. Consenting patients with clinical signs consistent with intra-anaesthetic AHR to a neuromuscular blocking agent were included. Severe AHR was defined as a Grade 3-4 of the Ring and Messmer classification. Causes of AHR were explored following recommended guidelines.
Among the 86 patients, 50% had severe AHR and 69% had a confirmed/suspected IgE-mediated event. Occurrence and minimum values of arterial hypotension, hypocapnia and hypoxaemia increased significantly with the severity of AHR. Low etCO2 was the only factor able to distinguish mild [median 3.5 (3.2;3.9) kPa] from severe AHR [median 2.4 (1.6;3.0) kPa], without overlap in inter-quartile range values, with an area under the receiver operator characteristic curve of 0.92 [95% confidence interval: 0.79-1.00]. Among the 41% of patients who received epinephrine, only half received it as first-line therapy despite international guidelines.
An etCO2 value below 2.6 kPa (20 mm Hg) could be useful for prompt diagnosis of severe intra-anaesthetic AHR, and could facilitate early treatment with titrated doses of epinephrine.
NCT01637220.
由于可能缺乏和/或难以检测到通常的临床体征，以及替代诊断的更高发生率，麻醉期间急性过敏反应（AHR）的快速诊断具有挑战性。由于诊断不正确/延迟，AHR 期间延迟给予肾上腺素可能与预后不良相关。已知呼气末二氧化碳（etCO2）低与心输出量低有关。然而，其在疑似麻醉期间 AHR 中的临床应用尚未得到充分记录。
分析了中性粒细胞激活在全身过敏反应（NASA）多中心研究中的 86 例患者的临床数据。纳入了具有与神经肌肉阻滞剂麻醉期间 AHR 一致的临床体征的同意患者。严重 AHR 定义为 Ring 和 Messmer 分类的 3-4 级。根据推荐的指南探讨了 AHR 的原因。
在 86 例患者中，有 50%发生严重 AHR，有 69%发生了确证/疑似 IgE 介导的事件。动脉低血压、低碳酸血症和低氧血症的发生和最低值随着 AHR 的严重程度显著增加。低 etCO2 是唯一能够区分轻度 AHR（中位数 3.5 [3.2；3.9] kPa）和严重 AHR [中位数 2.4（1.6；3.0）kPa]的因素，无重叠的四分位距值，受试者工作特征曲线下面积为 0.92 [95%置信区间：0.79-1.00]。在接受肾上腺素的 41%患者中，尽管有国际指南，但只有一半患者作为一线治疗使用。
etCO2 值低于 2.6kPa（20mmHg）可能有助于快速诊断严重麻醉期间 AHR，并促进使用滴定剂量的肾上腺素进行早期治疗。
NCT01637220。
