NAP 6 Perioperative Anaphylaxis Obstetrics Nuala Lucas OAA

NAP 6: Perioperative Anaphylaxis Obstetrics Nuala Lucas OAA

NAP 6: Perioperative Anaphylaxis What we knew before NAP 6 • Had received very limited prospective examination – available knowledge case reports/series & reviews Scottish Confidential Audit of Severe Maternal Morbidity Retrospective US review UK Obstetric Surveillance System 3/100, 000 births 2. 7 / 100, 000 deliveries 1. 6 / 100, 000 maternities

NAP 6: Perioperative Anaphylaxis Specific concerns for obstetrics Two ‘patients’ Broad differential diagnosis Latex allergy?

NAP 6: Perioperative Anaphylaxis Obstetric cases • 8 cases identified • NAP 6 Activity Survey estimated 233, 886 obstetric anaesthetics are administered PA in UK • Incidence of severe obstetric perioperative anaphylaxis of 3. 4 per 100, 000 (95% CI 1. 48 -6. 74 per 100, 000) • 6 cases associated with neuraxial anaesthesia, 2 cases associated with general anaesthesia

NAP 6: Perioperative Anaphylaxis Numerical analysis Operative procedure Category 1 CS Category 3 CS EUA/PPH Unknown 2 4 1 1

NAP 6: Perioperative Anaphylaxis Numerical analysis Operative procedure Category 1 CS Category 3 CS EUA/PPH Unknown 2 4 1 1 Timing Mon-Fri ‘daytime hours’ Out of hours 3 5

NAP 6: Perioperative Anaphylaxis Numerical analysis Operative procedure Category 1 CS Category 3 CS EUA/PPH Unknown 2 4 1 1 Timing Mon-Fri ‘daytime hours’ Out of hours 3 5 Anaesthetist Consultant NCCG Trainee 3 3 2

NAP 6: Perioperative Anaphylaxis Numerical analysis Operative procedure Category 1 CS Category 3 CS EUA/PPH Unknown 2 4 1 1 Timing Mon-Fri ‘daytime hours’ Out of hours 3 5 Anaesthetist for resus Consultant Unknown 7 1

NAP 6: Perioperative Anaphylaxis Presentation • 4/6 patients who developed anaphylaxis assoc with neuraxial anaesthesia complained of feeling unwell prior to the onset of hypotension or other clinical signs • ‘New’hypotension • In 4 cases (both GA and 2/6 neuraxial cases) there was prompt recognition of the clinical event • Only one case (neuraxial anaesthesia) was the event promptly recognised as anaphylaxis

NAP 6: Perioperative Anaphylaxis ‘New’ hypotension

NAP 6: Perioperative Anaphylaxis Management Chlorphenamine 5/8 Hydrocortisone 6/8 Fluid mx appropriate ? 5/8 Anaphylaxis pack 2/8

NAP 6: Perioperative Anaphylaxis Management Chlorphenamine 5/8 Hydrocortisone 6/8 Fluid mx appropriate ? 5/8 Anaphylaxis pack 2/8

NAP 6: Perioperative Anaphylaxis Outcomes Post event – No cardiac arrests • Aftercare – ITU/Recovery/Operating theatre/Observation bay on LW – 2/2/2/2 – 3/5 delayed hospital discharge – One woman reported anxiety re future anaesthetics Baby • 5/6 caesarean section cases – onset after delivery of baby – 1/6 onset immediately before delivery of baby

NAP 6: Perioperative Anaphylaxis Culprits

NAP 6: Perioperative Anaphylaxis • Individual Recommendations An allergy history should be taken even when there is extreme urgency to deliver the baby • Institutional Anaesthetists should be vigilant to non-obstetric causes of hypotension in obstetric patients Obstetric units should ensure immediate availability of anaesthetic anaphylaxis treatment and investigation packs wherever general or regional anaesthesia is administered Anaphylaxis should be actively considered where the cause of maternal hypotension or collapse is unclear, and mast cell tryptase levels should be measured Anaphylaxis in obstetric patients should be managed following the same principles as in nonobstetric patients. Anaesthetists should be aware that hypotension due to anaphylaxis can be exacerbated by neuraxial blockade and or aortocaval compression

NAP 6: Perioperative Anaphylaxis Other findings - choice of induction agent 100 75 THIOPENTAL 50 PROPOFOL 25 0 2015 2017

NAP 6: Perioperative Anaphylaxis Any questions?