Perioperative anaphylaxis is a rare, life\u2011threatening condition during anesthesia. The unique setting \u2013 multiple drugs, patient draping, and altered physiology \u2013 causes higher mortality than anaphylaxis elsewhere. This review covers evolving etiology, pathophysiology, atypical presentation, evidence\u2011based management, and prevention. Primary triggers include neuromuscular blocking agents, antibiotics, and latex, with emerging culprits (chlorhexidine, dyes, remimazolam). Diagnosis is challenging due to few cutaneous signs; cardiovascular collapse with low end\u2011tidal CO2 is a key supportive indicator. Immediate management prioritizes epinephrine and aggressive fluids. Post\u2011event allergological testing (skin tests, tryptase\/histamine) identifies the culprit. Prevention includes history\u2011taking, risk stratification, and latex\u2011free environments. Future directions: global surveillance, novel biomarkers (circulating microbiome), and simulation training.<\/p>\n
Introduction<\/p>\n
Incidence 1:2,000\u20131:20,000 procedures, but mortality higher than community anaphylaxis. Diagnosis<\/a> difficult due to anesthesia\u2011induced changes, lack of patient feedback, and multiple triggers. This narrative review synthesizes recent evidence (2017\u20132025).<\/p>\n Pathophysiology and evolving etiology<\/p>\n Primarily IgE\u2011mediated mast cell\/basophil degranulation; non\u2011IgE reactions also occur. Mediators cause vasodilation, capillary leak, bronchoconstriction.<\/p>\n Primary triggers: NMBAs (most common), \u03b2\u2011lactam antibiotics, latex (declining with avoidance).<\/p>\n Emerging triggers: Chlorhexidine, patent blue dye, remimazolam (case reports; cross\u2011reactivity with midazolam inconclusive).<\/p>\n High\u2011risk for latex: spina bifida, chronic bladder catheterization, healthcare workers, multiple surgeries.<\/p>\n Experimental: Pilot study found distinct circulating bacterial DNA (Enterobacteriaceae, Veillonellaceae) in NMBA\u2011allergic patients, correlating with tryptase\/IgE \u2013 exploratory, needs validation.<\/p>\n Diagnostic challenges and advances<\/p>\n Atypical presentation: Cutaneous signs rare; initial sign often cardiovascular collapse (severe hypotension), mistaken for anesthetic effects.<\/p>\n Key indicator: Low ETCO2 with hypotension \u2013 mean lowest ETCO2 17 mmHg in anaphylaxis vs. 32 mmHg in other causes (AUC 0.95; cutoff ~23 mmHg: 92% sensitive, 94% specific). Not specific (also hemorrhage, PE), but valuable clue.<\/p>\n
Bronchospasm: often severe, increased airway pressure.<\/p>\n Serum tryptase: elevated in ~71% of perioperative hypersensitivity reactions.<\/p>\n Plasma histamine: early, short half\u2011life; sample immediately and within 1\u20132 hours (threshold ~1.5 ng\/mL at 30 min).<\/p>\n Immediate management and post\u2011event investigation<\/p>\n Acute resuscitation: Stop potential triggers, 100% O2, aggressive crystalloids, epinephrine (IM\/IV titrated). Epinephrine first\u2011line; large volumes often needed.<\/p>\n Post\u2011stabilization:<\/p>\n Skin testing (prick\/intradermal) \u2013 cornerstone; traditionally 4\u20136 weeks post\u2011reaction.<\/p>\n Drug provocation tests \u2013 for high suspicion with negative skin tests; definitive but high risk, only in expert centers.<\/p>\n In vitro specific IgE for latex, some NMBAs, antibiotics.<\/p>\n Prevention and future directions<\/p>\n Limitations<\/p>\n Narrative review; evidence for emerging triggers from case reports\/small series; microbiome findings preliminary; recommendations may need local adaptation.<\/p>\n Conclusions<\/p>\n Perioperative anaphylaxis is a dynamic challenge. Masked presentation requires high suspicion, guided by profound hypotension with low ETCO2. Acute management: swift epinephrine and volume expansion. Long\u2011term safety relies on systematic prevention \u2013 risk\u2011aware evaluation, awareness of traditional and emerging triggers, and allergen avoidance. Future: surveillance, biomarkers, novel agent evaluation, and team training.\u00a0<\/p>\n The study was recently published in the\u00a0Exploratory Research and Hypothesis in Medicine.<\/p>\n Source:<\/p>\n Journal reference:<\/p>\n Lian, H., et al. (2026). Perioperative Anaphylaxis: Etiology, Pathophysiology, Diagnostic Challenges, Immediate Management, Prevention Strategies, and Future Perspectives. Exploratory Research and Hypothesis in Medicine. DOI: 10.14218\/erhm.2025.00079.\u00a0https:\/\/www.xiahepublishing.com\/2472-0712\/ERHM-2025-00079<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"Perioperative anaphylaxis is a rare, life\u2011threatening condition during anesthesia. The unique setting \u2013 multiple drugs, patient draping, and…\n","protected":false},"author":2,"featured_media":232898,"comment_status":"","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[10],"tags":[12743,64,63,14109,1730,34625,137,265036,342168,1679,5914,10484,32097,165263,11750,337,20198],"class_list":["post-702890","post","type-post","status-publish","format-standard","has-post-thumbnail","category-health","tag-anaphylaxis","tag-au","tag-australia","tag-diagnostic","tag-drugs","tag-epinephrine","tag-health","tag-histamine","tag-hypotension","tag-medicine","tag-microbiome","tag-mortality","tag-pathophysiology","tag-perioperative","tag-physiology","tag-research","tag-skin"],"_links":{"self":[{"href":"https:\/\/www.newsbeep.com\/au\/wp-json\/wp\/v2\/posts\/702890","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.newsbeep.com\/au\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.newsbeep.com\/au\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/au\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/au\/wp-json\/wp\/v2\/comments?post=702890"}],"version-history":[{"count":0,"href":"https:\/\/www.newsbeep.com\/au\/wp-json\/wp\/v2\/posts\/702890\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/au\/wp-json\/wp\/v2\/media\/232898"}],"wp:attachment":[{"href":"https:\/\/www.newsbeep.com\/au\/wp-json\/wp\/v2\/media?parent=702890"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.newsbeep.com\/au\/wp-json\/wp\/v2\/categories?post=702890"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.newsbeep.com\/au\/wp-json\/wp\/v2\/tags?post=702890"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}
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