Epidemiologic Notes and Reports Anaphylactic Reactions During General Anesthesia Among Pediatric Patients -- United States, January 1990 - January 1991

From March 1990 through January 1991, nine patients at one children's hospital in Wisconsin (hospital A) had onset of anaphylactic reactions (ARs) within 30 minutes following the start of general anesthesia; no patient had had a surgical incision at the time of their reaction. Eight of these patients required admission to the intensive care unit for supportive care. To determine the extent and potential source of the problem, an epidemiologic investigation was conducted at hospital

An AR was defined as hypotension (greater than or equal to 30 mm Hg fall in systolic blood pressure from the preinduction blood pressure) and at least one of the following during a general anesthesia procedure at hospital A from January 1989 through January 1991: rash, angioedema, stridor, wheezing, or bronchospasm. Review of anesthesia records identified a total of 11 case-patients, representing 12 ARs. All were pediatric patients aged 3-14 years (mean: 6.9 years). Ten of these patients had a meningomyelocele (i.e., spina bifida), and one patient had a congenital genitourinary tract abnormality. In addition, the risk for AR was higher among patients with a meningomyelocele and/or congenital genitourinary abnormality than among all other surgical patients (12/152 vs. 0/7684, p less than 0.001).

The investigation also included a case-control study of the 11 case-patients and all noncase-patients with a meningomyelocele (n=64) who had undergone general anesthesia at hospital A from January 1990 through January 1991 (controls). Case- and control-patients were similar with respect to age, sex, race, day of surgery, anesthesiology personnel, preoperative medications, type of anesthesia induction, anesthetic gas, surgical procedure, and receipt of intraoperative antimicrobials. Case-patients were, however, more likely to have a history of allergy (odds ratio (OR)=4.8; 95% confidence interval (CI)=1.1-23.3), asthma (OR=7.6; 95% CI=1.0-61.7), or multiple surgical procedures (p=0.04). Before their ARs, all case-patients had been exposed to the anesthesia circuitry and had intravenous catheters in place. Ten of the 11 case-patients reportedly had skin, radioallergosorbent, and/or enzyme-linked immunosorbent assay tests suggesting latex allergy; one patient was not tested.

Personnel at hospital A have instituted the following measures to minimize the risk for ARs among patients with a meningomyelocele or congenital genitourinary dysplasias: 1) use of nonlatex supplies during routine care and surgical procedures and 2) combined administration of H2-blockers, corticosteroids, and diphenhydramine hydrochloride during the 24-hour periods before and after all scheduled surgical procedures. Although no further ARs have occurred, the efficacy of these interventions has not been evaluated.

Preliminary results of a nationwide survey of children's hospitals have identified at least 25 other institutions that have reported similar reactions since January 1990 among approximately 75 patients (range: 1-6 patients per institution) with a meningomyelocele and/or congenital genitourinary dysplasias. Reported by: K Kelly, MD, Dept of Allergy Immunology, M Setlock, MD, Dept of Anesthesiology, Medical College of Wisconsin, Milwaukee; JP Davis, MD, State Epidemiologist, Wisconsin Dept of Health and Social Svcs. Center for Devices and Radiologic Health, Food and Drug Administration. Div of Birth Defects and Developmental Disabilities, National Center for Environmental Health and Injury Control; Div of Field Epidemiology, Epidemiology Program Office; Chronic Disease Surveillance Br, Office of Surveillance and Analysis, National Center for Chronic Disease Prevention and Health Promotion; Epidemiology Br, Hospital Infections Program, National Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note:

ARs during surgery are a rare but life-threatening complication. Although these reactions are commonly attributed to anesthetic agents, muscle relaxants, or antimicrobials that are administered intraoperatively, water-soluble proteins in latex are now well-recognized allergens in IgE-mediated ARs (1-3). Many commonly used medical products (e.g., gloves, endotracheal tubes, and urinary catheters) are latex-derived, and reports of ARs among persons in the United States who are exposed to latex-containing medical devices (e.g., barium enema tips) and other consumer products have increased substantially (4). Because patients with meningomyelocele and genitourinary dysplasias undergo multiple surgical procedures and frequently require clean intermittent bladder catheterization, these patients may be at increased risk for developing latex sensitization. Therefore, until the exact mechanism of these ARs is determined, postponement of elective surgical procedures for these patients should be considered. If surgical procedures are performed, consideration should be given to avoidance of unnecessary patient exposure to latex by presurgical washing and wiping of gloves in an area away from the patient. Epidemiologic and laboratory studies are underway to further assess the relation between exposure to latex antigens and ARs.

The Food and Drug Administration has recommended that all patients be questioned for potential latex allergy, particularly those with spina bifida or any patient scheduled for diagnostic and/or surgical procedures. Once latex allergy is suspected, use of nonlatex items should be considered (4).

Physicians are requested to report all episodes of anaphylaxis during procedures requiring general anesthesia through state health departments to the Epidemiology Branch, Hospital Infections Program, in CDC's National Center for Infectious Diseases; telephone (404) 639-1550.

References

1. Moscicki RA, Sockin SM, Corsello BF, et al. Anaphylaxis during induction of general anesthesia: subsequent evaluation and management. J Allergy Clin Immunol 1990;86:325-32.

2. Swartz JS, Braude BM, Gilmour RF, et al. Intraoperative anaphylaxis to latex. Can J Anaesth 1990;37:589-92.

3. Sussman GL, Tarlo S, Dolovich J. The spectrum of IgE-mediated responses to latex. JAMA 1991;265:2844-7.

4. Food and Drug Administration. Allergic reactions to latex-containing medical devices (Press release). Rockville, Maryland: Food and Drug Administration, March 29, 1991.

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