“Adverse drug reactions are a common cause of anaesthetic-related morbidity and mortality in healthy patients. They include drug intolerance or immune-mediated reactions, including anaphylaxis.

Allergic anaphylaxis has an incidence between 1/5000–1/20 000 with a 3:1 female preponderance. Despite initially increased reporting of adverse events to new drugs (Weber effect), there is generally under reporting to databases (e.g. the UK yellow card system). Anaphylaxis-related mortality is 3–6% and an additional 2% have a poor neurological outcome.”

Case study 1

A 49-yr-old female underwent an elective laparoscopic cholecystectomy. She had allergic rhinitis but was otherwise well. Her preoperative blood pressure (BP) was 140/80. One previous anaesthetic was uneventful. After 2 mg midazolam, 180 mg propofol, and 40 mg of rocuronium, she was intubated and volatile anaesthesia commenced. On transfer to theatre, she became flushed and tachycardic. Her airway pressure increased to >30 cmH2O and BP decreased to 65/40. Anaphylaxis was suspected and was treated with two boluses of 100 µg of i.v. epinephrine, 2 litres of crystalloid, i.v. hydrocortisone 200 mg and chlorphenamine 10 mg. She recovered overnight in the critical care area and was referred for allergy testing.

Case study 2

A 65-yr-old male had a central venous line inserted under local anaesthesia in theatre. He had no allergic history. Pre-insertion, the anaesthetist applied latex gloves, prepared the skin with alcoholic chlorhexidine, and injected 1% lidocaine. Immediately post central line insertion, the patient became flushed, developed a rash, abdominal pain, sweating, and felt unwell. He was immediately given hydrocortisone 100 mg and chlorphenamine 10 mg. The line was promptly replaced with a non-coated alternative.

Case study 3

A 69-yr-old female was referred by a community dentist to exclude LA allergy. She had noticed episodes of dysphoria and palpitations during past dental treatments and developed urticaria on her forearm after hand surgery under LA using Lignospan. The patient was consented for LA challenging with i.v. access and vital signs monitoring.

Read the case studies published in Continuing Education in Anaesthesia, Critical Care & Pain.