• Robert E Freundlich, Neal M Duggal, Michelle Housey, Tyler T Tremper, Milo C Engoren, and Sachin Kheterpal.
• Department of Anesthesiology, Vanderbilt University Medical Center, 1211 21st Ave S, Suite 526, Nashville, TN 37212. Electronic address: Robert.e.freundlich@vanderbilt.edu.
• J Clin Anesth. 2016 Dec 1; 35: 415-423.

Study ObjectiveTo facilitate the identification of drugs and patient factors associated with hemodynamically significant anaphylaxis.DesignUsing an existing database containing complete perioperative records, instances of hemodynamically significant anaphylaxis were identified using a physiologic and treatment-based screening algorithm. All cases were manually reviewed by 2 clinicians, with a third adjudicating disagreements, and confirmed cases were matched 3:1 with control cases. Intraoperative medications given in instances of hemodynamically significant anaphylaxis and patient risk factors were compared with control cases.SettingUniversity of Michigan Hospital, a large, tertiary care hospital.PatientsAll adult patients undergoing surgery between January 1, 2004, and January 5, 2015.InterventionsNone.MeasurementsIncidence of hemodynamically significant anaphylaxis during anesthesia. Patient risk factors and intraoperative medications associated with hemodynamically significant anaphylaxis.Main ResultsHemodynamically significant anaphylaxis occurred in 55 of 461 986 cases (1 in 8400). Hemodynamically significant anaphylaxis occurred in 52 patients, with 1 patient experiencing 3 instances and another patient 2 instances. Only 1 drug was associated with an increased risk of hemodynamically significant anaphylaxis: protamine (odds ratio, 11.78; 95% confidence interval, 1.40-99.26; P=.0233). No category of drugs was associated with increased risk. Of patient risk factors, only personal history of anaphylaxis was associated with an increased risk (odds ratio, 77.1; 95% confidence interval, 10.46-567.69; P=<.0001). Postoperative follow-up and evaluation of patients were low at our institution. A serum tryptase level was sent in only 49% of cases, and 41% of levels were positive, an overall positive rate of 20% of cases. Following instances of hemodynamically significant anaphylaxis, only 29% of patients were seen and evaluated by an allergist at our institution.ConclusionsHemodynamically significant anaphylaxis is a rare complication of anesthesia, with an incidence consistent with the existing literature. Contrary to most existing literature, only protamine was associated with increased risk. A personal history of anaphylaxis appears to best predict risk of hemodynamically significant anaphylaxis.Copyright © 2016 Elsevier Inc. All rights reserved.

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