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Chlorhexidine is a common cause of perioperative anaphylaxis, and global regulatory authorities have issued warnings about anaphylaxis due to chlorhexidine-containing central venous catheters (CVC) and its mucosal absorption. We present a case of life-threatening anaphylaxis after CVC insertion caused by chlorhexidine used for skin preparation. The onset of anaphylaxis was rapid and very severe, resulting in pulseless electrical activity. The patient was successfully resuscitated by emergency veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Our case suggests that even skin preparation before chlorhexidine-free CVC insertion can cause life-threatening anaphylaxis. We reviewed the literature on chlorhexidine anaphylaxis cases and categorized all potential routes of chlorhexidine exposure to assess the risk following skin preparation. Our results showed that skin preparation before CVC insertion was the third most common cause of chlorhexidine anaphylaxis after transurethral exposure and chlorhexidine-containing CVCs. However, skin preparation with chlorhexidine before CVC insertion was sometimes overlooked as a cause of chlorhexidine anaphylaxis, and its risk might be underestimated. Further, no previous reports have described life-threatening anaphylaxis solely due to chlorhexidine skin preparation before CVC insertion. CVC insertion might cause the chlorhexidine used for skin preparation to reach the vascular system and should be recognized as a potential cause of life-threatening chlorhexidine anaphylaxis., Author(s): Yasuhiro Amano [sup.1], Akari Matsuura [sup.1], Takahiro Tamura [sup.1], Yuki Kato [sup.1], Natsumi Kameyama [sup.2], Tomonori Takazawa [sup.3], Kimitoshi Nishiwaki [sup.1] Author Affiliations: (1) grid.437848.4, 0000 0004 0569 8970, [...]

Purpose From the perspective of infection prevention during the Coronavirus disease 2019 (COVID-19) pandemic, a recommendation was made to use surgical masks after extubation in patients in the operating room. For compliance with this recommendation, anesthesiologists need to administer oxygen to the patient with an oxygen mask over the surgical mask. However, no studies have investigated whether this method allows good maintenance of oxygenation in patients. This study aimed to investigate which method of oxygen administration lends itself best to use with a surgical mask in terms of oxygenation. Method We administered oxygen to the study subjects using all the following three methods in random order: an oxygen mask over or under a surgical mask and a nasal cannula under the surgical mask. Oxygenation was assessed using the oxygen reserve index (ORi) and end-tidal oxygen concentration (EtO.sub.2). Result This study included 24 healthy volunteers. ORi values with administration of oxygen were higher in the order of a nasal cannula under the surgical mask, an oxygen mask under the surgical mask, and an oxygen mask over the surgical mask, with median values of 0.50, 0.48, and 0.43, respectively, and statistically significant differences between all groups (P < 0.001). EtO.sub.2 values were in the same order as ORi, with median values of 33.0%, 31.0%, and 25%, respectively, and statistically significant differences between all groups (P < 0.001). Conclusion Wearing a surgical mask over the nasal cannula during oxygen administration is beneficial for oxygenation and might help prevent aerosol dispersal., Author(s): Yusuke Matsui [sup.1], Tomonori Takazawa [sup.2], Akihito Takemae [sup.1], Yukie Murooka [sup.1], Masafumi Kanamoto [sup.2], Shigeru Saito [sup.1] Author Affiliations: (1) grid.256642.1, 0000 0000 9269 4097, Department of Anesthesiology, [...]

Perioperative anaphylaxis is a severe adverse event during anesthesia that requires prompt diagnosis and treatment by physicians, including anesthesiologists. Muscle relaxants and antibiotics are the most common drugs that cause perioperative anaphylaxis in Japan, as in many countries. In addition, sugammadex appears to be a primary causative agent. Obtaining previous anesthesia records is necessary in a patient with a history of allergic reactions during anesthesia, whenever possible, to avoid recurrence of anaphylaxis. Although medical staff are likely to notice abnormal vital signs because of complete monitoring during anesthesia, surgical drapes make it difficult to notice the appearance of skin symptoms. Even if there are no skin symptoms, anaphylaxis should be suspected, especially when hypotension resistant to inotropes and vasopressors persists. For improving the diagnostic accuracy of anaphylaxis, it is helpful to collect blood samples to measure histamine/tryptase concentrations immediately after the events and at baseline. The first-line treatment for anaphylaxis is adrenaline. In the perioperative setting, adrenaline should be administered through the intravenous route, which has a faster effect onset and is secured in most cases. Adrenaline can cause serious complications including severe arrhythmias if the appropriate dose is not selected according to the severity of symptoms. The anesthesiologist should identify the causative agent after adverse events. The gold standard for identifying the causative agent is the skin test, but in vitro tests including specific IgE antibody measurements and basophil activation tests are also beneficial. The Working Group of the Japanese Society of Anesthesiologists has developed this practical guide to help appropriate prevention, early diagnosis and treatment, and postoperative diagnosis of anaphylaxis during anesthesia. Grade of recommendations and levels of evidence Anaphylaxis is a relatively rare condition with few controlled trials, and thus a so-called evidence-based scrutiny is difficult. Therefore, rather than showing evidence levels and indicating the level of recommendation, this practical guideline only describes the results of research available to date. The JSA will continue to investigate anaphylaxis during anesthesia, and the results may lead to an amendment of this practical guideline., Author(s): Tomonori Takazawa [sup.1], Ken Yamaura [sup.2], Tetsuya Hara [sup.3], Tomoko Yorozu [sup.4], Hiromasa Mitsuhata [sup.5], Hiroshi Morimatsu [sup.6] Author Affiliations: (1) grid.411887.3, 0000 0004 0595 7039, Intensive Care Unit, [...]

Anaphylactic shock is a potentially lethal complication during anesthesia and requires appropriate management to save the patient's life. We report a 32-year-old man who developed anaphylaxis during induction of general anesthesia with remimazolam for hand surgery. He received general anesthesia with midazolam 4 weeks before. This time facial flushing followed by a decrease of peripheral oxygen saturation (SpO.sub.2) and blood pressure occurred 2 min after starting continuous remimazolam infusion at 6 mg/kg/h. Hypotension and SpO.sub.2 were recovered by repeated administration of adrenaline. Despite no increase of serum tryptase levels, intradermal allergy tests 4 weeks postoperatively revealed that remimazolam and midazolam were positive, suggesting remimazolam as a causative agent for anaphylaxis. In the previous surgery, midazolam, which has a similar structure to remimazolam, may have caused sensitization. This is probably the first case report of anaphylaxis caused by remimazolam., Author(s): Kota Tsurumi [sup.1], Shinji Takahashi [sup.1], Yoshiyuki Hiramoto [sup.1], Kazuhiro Nagumo [sup.2], Tomonori Takazawa [sup.2], Yoichiro Kamiyama [sup.1] Author Affiliations: (1) grid.258269.2, 0000 0004 1762 2738, Department of Anesthesiology [...]

Since perioperative anaphylaxis occurs suddenly, and it can be life-threatening, anesthesiologists need to have sufficient knowledge of the epidemiology of perioperative anaphylaxis and appropriate coping strategies to deal with it. Recent studies conducted in Western countries reported the characteristics of perioperative anaphylaxis in each country. However, there are few studies of perioperative anaphylaxis in Japan. To bridge the gap between Japan and other countries, the data of 46 anaphylaxis patients at Gunma University Hospital and 13 neighboring hospitals between 2012 and 2018 were collected and analyzed. The recently developed clinical scoring system was combined with a skin test to include only cases with a definite diagnosis. The most common causative agents were sugammadex, followed by rocuronium, cefazolin, and antibiotics other than cefazolin. Furthermore, the characteristics of anaphylaxis for each causative drug were identified. Time from drug administration to appearance of the first symptom was the longest in the cefazolin group. The incidence of canceled operation was the highest in the rocuronium group. Although it is unclear whether the results of this study can apply to Japan as a whole, the information about the agents responsible for perioperative anaphylaxis and the characteristics of anaphylaxis due to each agent would be helpful to anesthesiologists., Author(s): Tatsuo Horiuchi [sup.1], Tomonori Takazawa [sup.2], Masaki Orihara [sup.1], Shinya Sakamoto [sup.1], Kazuhiro Nagumo [sup.1], Shigeru Saito [sup.1] [sup.2] Author Affiliations: (1) grid.256642.1, 0000 0000 9269 4097, Department of [...]

Author(s): Keiko Suzuki [sup.1] , Tomonori Takazawa [sup.1] , Shigeru Saito [sup.1] [sup.2 ] Author Affiliations: (1) grid.411887.3, 0000 0004 0595 7039, Intensive Care Unit, Gunma University Hospital, , 3-39-15 [...]

Skin tests are the gold standard for detecting the culprit drug of anaphylaxis, and should ideally be performed after an interval of 4-6 weeks after the reaction to avoid false-negative results. However, when re-operation cannot be delayed and early allergy tests are necessary, special attention is required during subsequent anesthesia, because early skin tests tend to produce false-negative results. This report presents a case of rocuronium-induced anaphylaxis in which early skin tests showed negative results for all the drugs tested. The second anesthesia was safely performed by avoiding all the drugs used for the first anesthesia. Ultimately, skin tests and basophil activation tests (BATs) performed after re-operation demonstrated rocuronium as the drug responsible for anaphylaxis. We recommend performing BATs in addition to skin tests to improve the accuracy of diagnosis of anaphylaxis. In this report, we also discuss interpretation of the results of early skin tests and subsequent selection of drugs for anesthesia. After postponement of surgery due to anaphylaxis, we are often required to perform allergy tests at an early stage if re-operation cannot be delayed. In such cases, skin test results alone should not be used to guide subsequent anesthesia management to avoid recurrent anaphylaxis., Author(s): Masaki Orihara [sup.1], Tomonori Takazawa [sup.2], Kazuhiro Nagumo [sup.2], Shinya Sakamoto [sup.1], Tatsuo Horiuchi [sup.1], Shigeru Saito [sup.1] Author Affiliations: (1) grid.256642.1, 0000 0000 9269 4097, Department of Anesthesiology, [...]

Purpose Infrahepatic inferior vena cava (IIVC) clamping is beneficial for reducing the amount of bleeding during hepatic surgery, although the associated systemic circulatory deterioration is noticeable. The relationship between changes in the degree of IIVC clamping and postoperative renal function was retrospectively evaluated. Methods A total of 59 patients who underwent elective hepatic surgery with surgical IIVC clamping in the two years were analyzed. In 2016, constant 80% clamping of the IIVC was performed (29 cases), and in 2017, hemodynamically adjusted IIVC clamping was performed (30 cases). Intraoperative parameters, including total blood loss and number of blood transfusions, were examined. The use of each vasoactive agents was analyzed. Renal function in the acute postoperative phase was evaluated using serum creatinine (Cr) and estimated glomerular filtration rate (eGFR) values. Results Comparison of the two groups showed that bolus doses of both ephedrine and phenylephrine were significantly higher in the 2016 group (P = 0.0221, 0.0017). Continuous doses of dopamine were significantly higher in the 2016 group, while those of noradrenaline were not. Postoperative serum Cr levels relative to baseline (%) were significantly higher in the 2016 group immediately after surgery and on postoperative day (POD) 1 (P = 0.0143, 0.0012). Postoperative eGFR relative to baseline (%) was significantly higher in the 2016 group immediately postoperatively and on PODs 1 and 2 (P = 0.0042, 0.0003, 0.0382). Conclusion Hemodynamically adjustable IIVC clamping might be superior to uniformly fixed clamping in preserving renal function without compromising the desired effect on hemostasis., Author(s): Jo Ohta [sup.1], Yuji Kadoi [sup.1], Yukie Murooka [sup.2], Hiroaki Matsuoka [sup.2], Masafumi Kanamoto [sup.2], Masaru Tobe [sup.2], Tomonori Takazawa [sup.2], Shigeru Saito [sup.1] Author Affiliations: (1) grid.256642.1, 0000 [...]

Purpose Identifying the causative agent of perioperative anaphylaxis is key to preventing its recurrence. Besides skin testing, the basophil activation test (BAT) is increasingly being accepted as an additional and reliable method. Cefazolin seems to be a major cause of perioperative anaphylaxis. However, few studies have described use of the BAT for cefazolin-induced anaphylaxis. In this study, we aimed to determine the optimum cefazolin concentration required in the BAT for an accurate diagnosis. Methods Seven patients who presented with immediate hypersensitivity to cefazolin and 21 control subjects were studied. We conducted skin tests and performed BATs using both CD203c and CD63 as markers of activated basophils. We measured the ratio of activated basophils after stimulation with serial dilutions of cefazolin and investigated the cefazolin concentration that resulted in better sensitivity and specificity. Results All patients demonstrated positive reactions to cefazolin, while all control subjects showed negative reactions on skin tests. The net percentage of both CD203c- and CD63-labeled activated basophils was greater when higher concentrations of cefazolin than previously reported were used. In control subjects, however, the number of activated basophils by cefazolin stimulation was negligible regardless of its concentration. In the case of CD203c, the sensitivity was 86% with a cefazolin concentration of 3 mg/ml, while in the case of CD63, the sensitivity was 100% with a cefazolin concentration of 10 mg/ml. Conclusion Using a higher concentration of cefazolin than previously reported for the BAT might increase the accuracy of diagnosis of cefazolin-induced anaphylaxis., Author(s): Tatsuo Horiuchi [sup.1] , Tomonori Takazawa [sup.2] , Masaki Orihara [sup.1] , Shinya Sakamoto [sup.1] , Akihiko Yokohama [sup.3] , Junko Takahashi [sup.4] , Akihiro Tomioka [sup.4] , Nagahide [...]