BULLETIN
CSQ-Bulletin93
CSQ-Bulletin93
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Page 17 | Bulletin 93 | September 2015<br />
www.niaa-hsrc.org.uk<br />
The 6th National Audit Project<br />
Perioperative Anaphylaxis<br />
Nigel Harper, MAHSC Honorary Clinical Professor of Anaesthesia and Perioperative Medicine, University of Manchester<br />
Tim Cook, Consultant in Anaesthesia and Intensive Care Medicine, Royal United Hospital Bath<br />
and Director of the National Audit Projects<br />
Perioperative Anaphylaxis was selected<br />
from a general call for submissions as<br />
the subject for the 6th National Audit<br />
Project (NAP) of the Royal College<br />
of Anaesthetists (RCoA) and, like<br />
previous NAPs, will involve every NHS<br />
hospital in the UK. This article is an<br />
introduction to the latest NAP.<br />
Why?<br />
Perioperative anaphylaxis is a rare lifethreatening<br />
event that is unexpected<br />
and unannounced, requiring immediate<br />
and skillful management followed by<br />
expert investigation. Anaphylaxis may<br />
not be the first diagnosis that comes to<br />
mind; there are much more common<br />
causes of perioperative hypotension<br />
and bronchospasm, for example.<br />
An individual anaesthetist may<br />
encounter only a handful of cases<br />
during their career, although many<br />
colleagues may consider they have<br />
already seen more than their quota.<br />
Important questions abound. What<br />
is the UK incidence of perioperative<br />
anaphylaxis? How many patients<br />
experience cardiac arrest as a result<br />
of perioperative anaphylaxis? What<br />
is the burden on intensive care<br />
services? What are the outcomes of<br />
perioperative anaphylaxis and what<br />
are the factors associated with poor<br />
outcome? Are some drugs more likely<br />
to cause anaphylaxis than others?<br />
Is perioperative anaphylaxis to<br />
chlorhexidine on the increase? Is latex<br />
allergy no longer a significant problem?<br />
Is there an epidemic of anaphylaxis<br />
to blue dye during breast surgery?<br />
How common and how severe is nonallergic<br />
perioperative anaphylaxis? Is<br />
the problem less or more frequent in<br />
children? Are some patients more prone<br />
to develop perioperative anaphylaxis<br />
than others? How many patients<br />
experience cardiac arrest as a result<br />
of perioperative anaphylaxis? What<br />
proportion of cases are reported to the<br />
Medicines and Healthcare products<br />
Regulatory Agency (MHRA) through the<br />
yellow-card system?<br />
Then there are questions relating<br />
to the immediate management<br />
of perioperative anaphylaxis. Is<br />
adrenaline really necessary in every<br />
patient? How much variation is there<br />
in the dose of adrenaline required?<br />
How often is it necessary to administer<br />
an infusion of adrenaline? How<br />
often is noradrenaline, vasopressin,<br />
glucagon or sugammadex used to<br />
treat perioperative anaphylaxis? How<br />
much intravenous fluid is actually<br />
administered during resuscitation?<br />
We have partial answers to a few of<br />
these many questions, but only a large<br />
UK-wide audit can offer the prospect<br />
of more complete knowledge and<br />
consequent patient benefit.<br />
Referring a patient for further<br />
investigation of suspected perioperative<br />
anaphylaxis should be straightforward,<br />
but how established are the referral<br />
routes from anaesthetist to allergy<br />
clinic? How many such specialist clinics<br />
exist in the UK? Is there geographical<br />
variation in specialist allergy clinic<br />
provision? Do the clinics provide a<br />
good service and do they make helpful<br />
recommendations to patients and<br />
anaesthetists? NAP6 also seeks to<br />
answer some of these questions and<br />
to point the way to potential service<br />
improvement with the collaboration of<br />
allergy professionals and patient groups.<br />
What and when?<br />
NAP6 is being conducted by the RCoA<br />
through the Health Services Research<br />
Centre (HSRC). The steering panel<br />
was convened in March 2015 and<br />
includes representation from the<br />
Association of Anaesthetists of Great<br />
Britain & Ireland, the Association<br />
of Paediatric Anaesthetists of Great<br />
Britain & Ireland, the Association for<br />
Perioperative Practice, the Faculty of<br />
Intensive Care Medicine, the HSRC,<br />
the MHRA, the Obstetric Anaesthetists’<br />
Association, the Research & Audit<br />
Federation of Trainees, the Royal<br />
Pharmaceutical Society and the Safe<br />
Anaesthesia Liaison Group, and also<br />
professional allergy organisations and<br />
patient groups.<br />
NAP6 will seek reports of every case<br />
meeting the following criteria during<br />
the data collection period:<br />
■■<br />
Grade 3, 4 and 5 reactions (i.e. –<br />
severe reactions, life-threatening<br />
reactions and deaths). Minor<br />
reactions such as localized rash<br />
or anticipated hypotension or<br />
bronchospasm will be excluded).