70-year-old man for Second shoulder surgery 

Background:

• 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

Issues

• 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.

Discussion:

• 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

Plan

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