Perioperative Anaphylaxis and Allergic Reactions

Perioperative anaphylaxis is an acute and potentially fatal hypersensitivity reaction occurring during the perioperative period, encompassing induction, maintenance and emergence from anaesthesia. Manifestations range from cutaneous symptoms, bronchospasm and cardiovascular collapse to multi-organ failure. The incidence is estimated at 1–10 per 10,000 anaesthetics globally, with a mortality rate of up to 10 per cent. Triggers include neuromuscular blocking agents, antibiotics, latex, antiseptics and colloids. Underlying mechanisms comprise IgE-mediated sensitisation and non-IgE pathways such as direct mast cell activation via receptors including MRGPRX2. Early recognition relies on vigilant monitoring of respiratory, cardiovascular and cutaneous signs, while prompt management with intravascular volume support, vasopressors and adrenaline is essential. Post-event work-up involves skin testing, in vitro assays and controlled re-exposure, aiming to identify the culprit agent and inform future anaesthetic planning. Recent advances in immunological assays and molecular diagnostics have improved risk stratification and patient safety. The global burden underscores the need for standardised protocols, cross-disciplinary collaboration and ongoing education to mitigate risk, personalise perioperative care and enhance long-term outcomes.

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Perioperative Anaphylaxis and Allergic Reactions publication trend

The graph below shows the total number of articles in perioperative anaphylaxis and allergic reactions across all publications each year (not limited to Nature Index journals).

Technical terms

Anaphylaxis: A rapid, severe systemic hypersensitivity reaction often involving respiratory compromise, cardiovascular collapse and mucocutaneous signs, mediated by mast cell and basophil degranulation.

Neuromuscular blocking agents (NMBAs): Drugs used during general anaesthesia to induce muscle relaxation; common examples include rocuronium, vecuronium and atracurium, which can provoke immune or non-immune reactions.

IgE-mediated hypersensitivity: An immune response in which antigen-specific immunoglobulin E antibodies bind to allergens, causing mast cell degranulation and release of mediators such as histamine.

Pseudo-allergic reaction: A non-IgE-mediated event in which a drug directly activates mast cells via receptors such as MRGPRX2, mimicking anaphylaxis but without classical sensitisation.

References

1. Adverse events related to neuromuscular blocking agents: a disproportionality analysis of the FDA adverse event reporting system. Frontiers in Pharmacology (2024).
2. Anaesthesia, surgery, and life-threatening allergic reactions: protocol and methods of the 6th National Audit Project (NAP6) of the Royal College of Anaesthetists. British Journal of Anaesthesia (2018).
3. Reclassifying Anaphylaxis to Neuromuscular Blocking Agents Based on the Presumed Patho-Mechanism: IgE-Mediated, Pharmacological Adverse Reaction or “Innate Hypersensitivity”?. International Journal of Molecular Sciences (2017).