Joint memorandum by Dr Nigel J N Harper
and Dr Richard Pumphrey (AL 41)
The process of anaesthesia in any individual
patient requires the administration of as many as 10 different
drugs, in high concentration, directly into the circulation. Approximately
five million anaesthetics are administered each year in the UK.
The incidence of life-threatening
anaesthetic anaphylaxis, extrapolated from the French register,
is approximately 1:10,000. There are no data for the UK.
Life-threatening anaesthetic anaphylaxis can
occur on first exposure because some of the antigenic determinants
are ubiquitous in everyday life. Conversely, a previous uneventful
anaesthetic is not predictive of safe future anaesthesia. There
is strong evidence of cross-sensitivity between some anaesthetic
drugs, ie the paralysing curare-type agents; six different drugs
of this type are in common use. If a patient survives anaphylaxis
to one of these drugs, the subsequent administration of a different
paralysing drug could cause fatal anaphylaxis.
Because patients are exposed to so many potential
allergens during anaesthesia, including skin antiseptics, antibiotics,
analgesics, anti-emetics, and latex, it is clear that each case
of anaesthetic anaphylaxis should be expertly investigated. For
each case of true allergic anaphylaxis there are approximately
four cases where the life-threatening event was not allergic in
origin.
The investigation of anaesthetic anaphylaxis
across the UK is currently extremely variable. In some geographical
areas, facilities are good, but the majority of the population
has no convenient access to an expert clinic. The British Society
of Allergists and Clinical Immunologists (BSACI) has identified
only nine allergists/immunologists in the UK who investigate anaesthetic
allergy. Some patients would need to travel over 100 miles to
a clinic.
Because the process of anaesthesia is complex,
it is important that these patients are investigated jointly
by an allergist/immunologists and an anaesthetist with
a special interest in anaesthetic allergy.
The Association of Anaesthetists of Great Britain
and Ireland (AAGBI) has worked with the BSACI for several years
and has produced joint clinical guidelines. The AAGBI is supporting
the development of a national database for anaesthetic anaphylaxis
and a web-based reporting process so that UK data can be collected.
The interdisciplinary outpatient clinic operated
for seven years by the authors of this submission is the first
of only two or three in the UK. Approximately 20 such expert joint
clinics are needed in the UK. Meetings organised by the authors
at the Royal College of Anaesthetists and the AAGBI have demonstrated
that there is no shortage of interested allergists/immunologists
and anaesthetists. What is needed is a relatively small amount
of funding to be made available nationally to expand existing
clinics and to develop new interdisciplinary clinics so that patients
can be expertly investigated regardless of where they live.
REFERENCES
Watkins J. Adverse reactions to muscle relaxants.
In Muscle Relaxants in Anaesthesia ed. Harper NJN, Pollard
BJ. Edward Arnold, London 1995.
Mertes P M. Laxenaire M-C. Allergic reactions
occurring during anaesthesia. European Journal of Anaesthesiology
2002; 19: 240-262.
Suspected Allergic Reactions Associated With
Anaesthesia. Published by AAGBI and BSACI August 2003.
Harper N J N. Anaesthetic Anaphylaxis: The Way
Forward. Anaesthesia News (AAGBI) May 2004.
June 2004
| 
