Anaphylaxis and subsequent surgery

70-year-old man for Second shoulder surgery 


  • Previous TSR – refractory hypotension intra-operatively
  • No response to metaraminol
  • Responded to small bolus and brief infusion of adrenaline
  • No other features of anaphylaxis
  • Surgery completed
  • Well postoperatively


  • Tryptases 7.3/10.3/5.4 – dynamic changes but not significant rise
  • Immunologist opinion that dynamic changes in tryptase make it difficult to exclude mast cell activity
  • Allergy testing – extensive tests performed including agents to which he had not been exposed
  • Several mild skin reactions to propofol, vecuronium, chlorhexidine, and tranexamic acid.
  • Nil reactions to other common allergens used on DOS
  • Normal IgE levels specific to chlorhex, morphine, and latex
  • Conclusion from testing – Avoid NMB used at time (rocuronium), use iodine instead of chlorhex. Avoid TXA if possible. Propofol most commonly irritant so safe to use.


  • Difficult situation
  • Non-allergic/Anaphylactoid – i.e., not an IgE mediated process? Not included in allergy testing 
  • See attached BJA article (doi: 10.1016/j.bjae.2019.06.002) on perioperative anaphylaxis

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  • Proceed with surgery and follow immunologist advice
  • Preoperative discussion with patient regarding above discussion