Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Perioperative anaphylaxis: Clinical manifestations, etiology, and management

Jerrold H Levy, MD, FAHA, FCCM
Dennis K Ledford, MD
Section Editor
John M Kelso, MD
Deputy Editors
Anna M Feldweg, MD
Nancy A Nussmeier, MD, FAHA


Patients undergoing general anesthesia and surgery can experience complex physiologic changes, which may complicate recognition of an allergic reaction.

The prevalence, etiology, risk factors, clinical manifestations, and acute diagnosis of anaphylaxis during general anesthesia will be reviewed here. The evaluation of a patient who has experienced perioperative anaphylaxis, skin testing to the drugs that cause immunoglobulin E (IgE)-mediated reactions, and prevention of recurrent reactions, as well as the treatment of anaphylaxis from any cause, are discussed separately. (See "Perioperative anaphylaxis: Evaluation and prevention of recurrent reactions" and "Anaphylaxis: Emergency treatment".)


The incidence of anaphylaxis during general anesthesia is 1:10,000 to 1:20,000 [1-5]. The wide variability in estimates of prevalence and incidence reflects the difficulties in determining the denominator (or the total number of anesthesia cases), as well as limitations in diagnosing perianesthetic anaphylaxis. Perioperative anaphylaxis occurs equally in prepubertal girls and boys, but is more common in adult women than men [3].


Anaphylaxis is an acute, potentially lethal, multisystem syndrome almost always resulting from the sudden release of mast cell- and basophil-derived mediators into the circulation [6-10]. (See "Pathophysiology of anaphylaxis".)

In this review (and increasingly in the literature), the term "anaphylaxis" applies to all of the following mechanisms of acute reactions (table 1) [11]:

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Apr 21, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Fisher MM, Baldo BA. The incidence and clinical features of anaphylactic reactions during anesthesia in Australia. Ann Fr Anesth Reanim 1993; 12:97.
  2. Laxenaire MC. [Epidemiology of anesthetic anaphylactoid reactions. Fourth multicenter survey (July 1994-December 1996)]. Ann Fr Anesth Reanim 1999; 18:796.
  3. Mertes PM, Alla F, Tréchot P, et al. Anaphylaxis during anesthesia in France: an 8-year national survey. J Allergy Clin Immunol 2011; 128:366.
  4. Mertes PM, Malinovsky JM, Jouffroy L, et al. Reducing the risk of anaphylaxis during anesthesia: 2011 updated guidelines for clinical practice. J Investig Allergol Clin Immunol 2011; 21:442.
  5. Mertes PM, Volcheck GW, Garvey LH, et al. Epidemiology of perioperative anaphylaxis. Presse Med 2016; 45:758.
  6. Sampson HA, Muñoz-Furlong A, Bock SA, et al. Symposium on the definition and management of anaphylaxis: summary report. J Allergy Clin Immunol 2005; 115:584.
  7. Sampson HA, Muñoz-Furlong A, Campbell RL, et al. Second symposium on the definition and management of anaphylaxis: summary report--Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium. J Allergy Clin Immunol 2006; 117:391.
  8. Lieberman P. Mechanisms of anaphylaxis beyond classically mediated antigen- and IgE-induced events. Ann Allergy Asthma Immunol 2017; 118:246.
  9. Vitte J, Bongrand P. Serum tryptase determination in patients with acute allergic reactions. J Allergy Clin Immunol 2013; 131:1714.
  10. Finkelman FD, Rothenberg ME, Brandt EB, et al. Molecular mechanisms of anaphylaxis: lessons from studies with murine models. J Allergy Clin Immunol 2005; 115:449.
  11. Johansson SG, Bieber T, Dahl R, et al. Revised nomenclature for allergy for global use: Report of the Nomenclature Review Committee of the World Allergy Organization, October 2003. J Allergy Clin Immunol 2004; 113:832.
  12. Mertes PM, Laxenaire MC, Lienhart A, et al. Reducing the risk of anaphylaxis during anaesthesia: guidelines for clinical practice. J Investig Allergol Clin Immunol 2005; 15:91.
  13. Chacko T, Ledford D. Peri-anesthetic anaphylaxis. Immunol Allergy Clin North Am 2007; 27:213.
  14. Genovese A, Stellato C, Marsella CV, et al. Role of mast cells, basophils and their mediators in adverse reactions to general anesthetics and radiocontrast media. Int Arch Allergy Immunol 1996; 110:13.
  15. Levy JH, Adkinson NF Jr. Anaphylaxis during cardiac surgery: implications for clinicians. Anesth Analg 2008; 106:392.
  16. McNeil BD, Pundir P, Meeker S, et al. Identification of a mast-cell-specific receptor crucial for pseudo-allergic drug reactions. Nature 2015; 519:237.
  17. Veien M, Szlam F, Holden JT, et al. Mechanisms of nonimmunological histamine and tryptase release from human cutaneous mast cells. Anesthesiology 2000; 92:1074.
  18. Trautmann A, Seidl C, Stoevesandt J, Seitz CS. General anaesthesia-induced anaphylaxis: impact of allergy testing on subsequent anaesthesia. Clin Exp Allergy 2016; 46:125.
  19. Dong SW, Mertes PM, Petitpain N, et al. Hypersensitivity reactions during anesthesia. Results from the ninth French survey (2005-2007). Minerva Anestesiol 2012; 78:868.
  20. Mertes PM, Demoly P, Malinovsky JM. Hypersensitivity reactions in the anesthesia setting/allergic reactions to anesthetics. Curr Opin Allergy Clin Immunol 2012; 12:361.
  21. Tacquard C, Collange O, Gomis P, et al. Anaesthetic hypersensitivity reactions in France between 2011 and 2012: the 10th GERAP epidemiologic survey. Acta Anaesthesiol Scand 2017; 61:290.
  22. Mertes PM, Laxenaire MC, Alla F, Groupe d'Etudes des Réactions Anaphylactoïdes Peranesthésiques. Anaphylactic and anaphylactoid reactions occurring during anesthesia in France in 1999-2000. Anesthesiology 2003; 99:536.
  23. Garvey LH, Roed-Petersen J, Menné T, Husum B. Danish Anaesthesia Allergy Centre - preliminary results. Acta Anaesthesiol Scand 2001; 45:1204.
  24. Meng J, Rotiroti G, Burdett E, Lukawska JJ. Anaphylaxis during general anaesthesia: experience from a drug allergy centre in the UK. Acta Anaesthesiol Scand 2017; 61:281.
  25. Harboe T, Guttormsen AB, Irgens A, et al. Anaphylaxis during anesthesia in Norway: a 6-year single-center follow-up study. Anesthesiology 2005; 102:897.
  26. Gurrieri C, Weingarten TN, Martin DP, et al. Allergic reactions during anesthesia at a large United States referral center. Anesth Analg 2011; 113:1202.
  27. Kuhlen JL Jr, Camargo CA Jr, Balekian DS, et al. Antibiotics Are the Most Commonly Identified Cause of Perioperative Hypersensitivity Reactions. J Allergy Clin Immunol Pract 2016; 4:697.
  28. Mertes PM, Tajima K, Regnier-Kimmoun MA, et al. Perioperative anaphylaxis. Med Clin North Am 2010; 94:761.
  29. Hwang MJ, Do JY, Choi EW, et al. Immunoglobulin E-mediated hypersensitivity reaction after intraperitoneal administration of vancomycin. Kidney Res Clin Pract 2015; 34:57.
  30. Minhas JS, Wickner PG, Long AA, et al. Immune-mediated reactions to vancomycin: A systematic case review and analysis. Ann Allergy Asthma Immunol 2016; 116:544.
  31. Birnbaum J, Porri F, Pradal M, et al. Allergy during anaesthesia. Clin Exp Allergy 1994; 24:915.
  32. Baldo BA, Fisher MM. Mechanisms in IgE-dependent anaphylaxis to anesthetic drugs. Ann Fr Anesth Reanim 1993; 12:131.
  33. Koppert W, Blunk JA, Petersen LJ, et al. Different patterns of mast cell activation by muscle relaxants in human skin. Anesthesiology 2001; 95:659.
  34. Doenicke AW, Czeslick E, Moss J, Hoernecke R. Onset time, endotracheal intubating conditions, and plasma histamine after cisatracurium and vecuronium administration. Anesth Analg 1998; 87:434.
  35. Baldo BA, Fisher MM. Substituted ammonium ions as allergenic determinants in drug allergy. Nature 1983; 306:262.
  36. Harboe T, Johansson SG, Florvaag E, Oman H. Pholcodine exposure raises serum IgE in patients with previous anaphylaxis to neuromuscular blocking agents. Allergy 2007; 62:1445.
  37. Florvaag E, Johansson SG, Oman H, et al. Prevalence of IgE antibodies to morphine. Relation to the high and low incidences of NMBA anaphylaxis in Norway and Sweden, respectively. Acta Anaesthesiol Scand 2005; 49:437.
  38. Johansson SG, Florvaag E, Oman H, et al. National pholcodine consumption and prevalence of IgE-sensitization: a multicentre study. Allergy 2010; 65:498.
  39. Jooste E, Klafter F, Hirshman CA, Emala CW. A mechanism for rapacuronium-induced bronchospasm: M2 muscarinic receptor antagonism. Anesthesiology 2003; 98:906.
  40. Chaiear N, Foulds I, Burge PS. Prevalence and risk factors for latex allergy. Occup Environ Med 2000; 57:501.
  41. Thong CL, Lambros M, Stewart MG, Kam PC. An unexpected cause of an acute hypersensitivity reaction during recovery from anaesthesia. Anaesth Intensive Care 2005; 33:521.
  42. Knight BA, Puy R, Douglass J, et al. Chlorhexidine anaphylaxis: a case report and review of the literature. Intern Med J 2001; 31:436.
  43. Parkes AW, Harper N, Herwadkar A, Pumphrey R. Anaphylaxis to the chlorhexidine component of Instillagel: a case series. Br J Anaesth 2009; 102:65.
  44. Garvey LH, Krøigaard M, Poulsen LK, et al. IgE-mediated allergy to chlorhexidine. J Allergy Clin Immunol 2007; 120:409.
  45. Krishna MT, York M, Chin T, et al. Multi-centre retrospective analysis of anaphylaxis during general anaesthesia in the United Kingdom: aetiology and diagnostic performance of acute serum tryptase. Clin Exp Immunol 2014; 178:399.
  46. Weng M, Zhu M, Chen W, Miao C. Life-threatening anaphylactic shock due to chlorhexidine on the central venous catheter: a case series. Int J Clin Exp Med 2014; 7:5930.
  47. Rutkowski K, Wagner A. Chlorhexidine: a new latex? Eur Urol 2015; 68:345.
  48. Hong CC, Wang SM, Nather A, et al. Chlorhexidine Anaphylaxis Masquerading as Septic Shock. Int Arch Allergy Immunol 2015; 167:16.
  49. Sharp G, Green S, Rose M. Chlorhexidine-induced anaphylaxis in surgical patients: a review of the literature. ANZ J Surg 2016; 86:237.
  50. Zinderman CE, Landow L, Wise RP. Anaphylactoid reactions to Dextran 40 and 70: reports to the United States Food and Drug Administration, 1969 to 2004. J Vasc Surg 2006; 43:1004.
  51. Wiedermann CJ. Hydroxyethyl starch--can the safety problems be ignored? Wien Klin Wochenschr 2004; 116:583.
  52. Leynadier F, Sansarricq M, Didier JM, Dry J. Prick tests in the diagnosis of anaphylaxis to general anaesthetics. Br J Anaesth 1987; 59:683.
  53. Fujita A, Kitayama M, Hirota K. Anaphylactoid shock in a patient following 5% human serum albumin infusion during off-pump coronary artery bypass grafting. J Anesth 2007; 21:396.
  54. Vervloet D, Senft M, Dugue P, et al. Anaphylactic reactions to modified fluid gelatins. J Allergy Clin Immunol 1983; 71:535.
  55. Russell WJ, Fenwick DG. Anaphylaxis to Haemaccel and cross reactivity to Gelofusin. Anaesth Intensive Care 2002; 30:481.
  56. Moscicki RA, Sockin SM, Corsello BF, et al. Anaphylaxis during induction of general anesthesia: subsequent evaluation and management. J Allergy Clin Immunol 1990; 86:325.
  57. Hirshman CA, Edelstein RA, Ebertz JM, Hanifin JM. Thiobarbiturate-induced histamine release in human skin mast cells. Anesthesiology 1985; 63:353.
  58. Baker MT, Naguib M. Propofol: the challenges of formulation. Anesthesiology 2005; 103:860.
  59. Marik PE. Propofol: therapeutic indications and side-effects. Curr Pharm Des 2004; 10:3639.
  60. Wang H, Cork R, Rao A. Development of a new generation of propofol. Curr Opin Anaesthesiol 2007; 20:311.
  61. Hofer KN, McCarthy MW, Buck ML, Hendrick AE. Possible anaphylaxis after propofol in a child with food allergy. Ann Pharmacother 2003; 37:398.
  62. Kelso JM. Potential food allergens in medications. J Allergy Clin Immunol 2014; 133:1509.
  63. Asserhøj LL, Mosbech H, Krøigaard M, Garvey LH. No evidence for contraindications to the use of propofol in adults allergic to egg, soy or peanut†. Br J Anaesth 2016; 116:77.
  64. Haybarger E, Young AS, Giovannitti JA Jr. Benzodiazepine Allergy With Anesthesia Administration: A Review of Current Literature. Anesth Prog 2016; 63:160.
  65. Palacios Benito R, Domínguez Ortega J, Alonso Llamazares A, et al. Adverse reaction to tetrazepam. J Investig Allergol Clin Immunol 2001; 11:130.
  66. Gooch I, Gwinnutt C. Anaphylaxis to intrathecal diamorphine. Resuscitation 2006; 70:470.
  67. Bennett MJ, Anderson LK, McMillan JC, et al. Anaphylactic reaction during anaesthesia associated with positive intradermal skin test to fentanyl. Can Anaesth Soc J 1986; 33:75.
  68. Levy JH, Brister NW, Shearin A, et al. Wheal and flare responses to opioids in humans. Anesthesiology 1989; 70:756.
  69. Yang WH, Purchase EC, Rivington RN. Positive skin tests and Prausnitz-Küstner reactions in metabisulfite-sensitive subjects. J Allergy Clin Immunol 1986; 78:443.
  70. Kendigelen P, BaktirClinic Of Anesthesiology And Reanimation Afşin State Hospital Afşin Kahramanmaraş Tureky M, Sucu A, Kaya G. Anaphylaxis after administration of amikacin containing sodium metabisulfite in a premature newborn. Arch Argent Pediatr 2016; 114:e195.
  71. Cifuentes L, Ring J, Brockow K. Clonal mast cell activation syndrome with anaphylaxis to sulfites. Int Arch Allergy Immunol 2013; 162:94.
  72. Kounis N, Kounis G. Anaphylactic cardiovascular collapse during anesthesia: the Kounis acute hypersensitivity syndrome seems to be the most likely cause. J Korean Med Sci 2013; 28:638.
  73. Cochico SG. Propofol allergy: assessing for patient risks. AORN J 2012; 96:398.
  74. López Sáez MP, de Barrio M, Zubeldia JM, et al. Acute IgE-mediated generalized urticaria-angioedema after topical application of povidone-iodine. Allergol Immunopathol (Madr) 1998; 26:23.
  75. Gray PE, Katelaris CH, Lipson D. Recurrent anaphylaxis caused by topical povidone-iodine (Betadine). J Paediatr Child Health 2013; 49:506.
  76. Blas M, Briesacher KS, Lobato EB. Bacitracin irrigation: a cause of anaphylaxis in the operating room. Anesth Analg 2000; 91:1027.
  77. Sprung J, Schedewie HK, Kampine JP. Intraoperative anaphylactic shock after bacitracin irrigation. Anesth Analg 1990; 71:430.
  78. Damm S. Intraoperative anaphylaxis associated with bacitracin irrigation. Am J Health Syst Pharm 2011; 68:323.
  79. Sharif S, Goldberg B. Detection of IgE antibodies to bacitracin using a commercially available streptavidin-linked solid phase in a patient with anaphylaxis to triple antibiotic ointment. Ann Allergy Asthma Immunol 2007; 98:563.
  80. Freiler JF, Steel KE, Hagan LL, et al. Intraoperative anaphylaxis to bacitracin during pacemaker change and laser lead extraction. Ann Allergy Asthma Immunol 2005; 95:389.
  81. Ebo DG, Bosmans JL, Couttenye MM, Stevens WJ. Haemodialysis-associated anaphylactic and anaphylactoid reactions. Allergy 2006; 61:211.
  82. Grammer LC, Roberts M, Wiggins CA, et al. A comparison of cutaneous testing and ELISA testing for assessing reactivity to ethylene oxide-human serum albumin in hemodialysis patients with anaphylactic reactions. J Allergy Clin Immunol 1991; 87:674.
  83. Suzukawa M, Komiya A, Koketsu R, et al. Three cases of ortho-phthalaldehyde-induced anaphylaxis after laryngoscopy: detection of specific IgE in serum. Allergol Int 2007; 56:313.
  84. Sokol WN. Nine episodes of anaphylaxis following cystoscopy caused by Cidex OPA (ortho-phthalaldehyde) high-level disinfectant in 4 patients after cytoscopy. J Allergy Clin Immunol 2004; 114:392.
  85. Cooper DE, White AA, Werkema AN, Auge BK. Anaphylaxis following cystoscopy with equipment sterilized with Cidex OPA (ortho-phthalaldehyde): a review of two cases. J Endourol 2008; 22:2181.
  86. Suzukawa M, Yamaguchi M, Komiya A, et al. Ortho-phthalaldehyde-induced anaphylaxis after laryngoscopy. J Allergy Clin Immunol 2006; 117:1500.
  87. McGrath KG, Patterson R. Anaphylactic reactivity to streptokinase. JAMA 1984; 252:1314.
  88. Pechlaner C, Knapp E, Wiedermann CJ. Hypersensitivity reactions associated with recombinant tissue-type plasminogen activator and urokinase. Blood Coagul Fibrinolysis 2001; 12:491.
  89. Haque RA, Wagner A, Whisken JA, et al. Anaphylaxis to patent blue V: a case series and proposed diagnostic protocol. Allergy 2010; 65:396.
  90. Scherer K, Studer W, Figueiredo V, Bircher AJ. Anaphylaxis to isosulfan blue and cross-reactivity to patent blue V: case report and review of the nomenclature of vital blue dyes. Ann Allergy Asthma Immunol 2006; 96:497.
  91. Tripathy S, Nair PV. Adverse drug reaction, patent blue V dye and anaesthesia. Indian J Anaesth 2012; 56:563.
  92. Low AE, McEwan JC, Karanam S, et al. Anaesthesia-associated hypersensitivity reactions: seven years' data from a British bi-specialty clinic. Anaesthesia 2016; 71:76.
  93. Pinkowski JL, Leeson MC. Anaphylactic shock associated with chymopapain skin test. A case report and review of the literature. Clin Orthop Relat Res 1990; :186.
  94. Smith MB, Hofmann VC. Anaphylactoid reaction to chymopapain. Anaesthesia 1989; 44:767.
  95. Nordby EJ, Wright PH, Schofield SR. Safety of chemonucleolysis. Adverse effects reported in the United States, 1982-1991. Clin Orthop Relat Res 1993; :122.
  96. Moneret-Vautrin DA, Feldmann L, Kanny G, et al. Incidence and risk factors for latent sensitization to chymopapain: predictive skin-prick tests in 700 candidates for chemonucleolysis. Clin Exp Allergy 1994; 24:471.
  97. Wonders J, Eekhoff EM, Heine R, et al. [Insulin allergy: background, diagnosis and treatment]. Ned Tijdschr Geneeskd 2005; 149:2783.
  98. Grammer L. Insulin allergy. Clin Rev Allergy 1986; 4:189.
  99. Phillips JF, Yates AB, Deshazo RD. Approach to patients with suspected hypersensitivity to local anesthetics. Am J Med Sci 2007; 334:190.
  100. Ring J, Franz R, Brockow K. Anaphylactic reactions to local anesthetics. Chem Immunol Allergy 2010; 95:190.
  101. Veach SA, Franks AM, Allan MC. Severe anaphylactic reaction after repeated intermittent exposure to lepirudin. Pharmacotherapy 2007; 27:760.
  102. Bircher AJ, Harr T, Hohenstein L, Tsakiris DA. Hypersensitivity reactions to anticoagulant drugs: diagnosis and management options. Allergy 2006; 61:1432.
  103. Berkun Y, Haviv YS, Schwartz LB, Shalit M. Heparin-induced recurrent anaphylaxis. Clin Exp Allergy 2004; 34:1916.
  104. Mozzicato SM, Tripathi A, Posthumus JB, et al. Porcine or bovine valve replacement in 3 patients with IgE antibodies to the mammalian oligosaccharide galactose-alpha-1,3-galactose. J Allergy Clin Immunol Pract 2014; 2:637.
  105. Uyttebroek A, Sabato V, Bridts CH, et al. Anaphylaxis to succinylated gelatin in a patient with a meat allergy: galactose-α(1, 3)-galactose (α-gal) as antigenic determinant. J Clin Anesth 2014; 26:574.
  106. Khoriaty E, McClain CD, Permaul P, et al. Intraoperative anaphylaxis induced by the gelatin component of thrombin-soaked gelfoam in a pediatric patient. Ann Allergy Asthma Immunol 2012; 108:209.
  107. Spencer HT, Hsu JT, McDonald DR, Karlin LI. Intraoperative anaphylaxis to gelatin in topical hemostatic agents during anterior spinal fusion: a case report. Spine J 2012; 12:e1.
  108. Park KW. Protamine and protamine reactions. Int Anesthesiol Clin 2004; 42:135.
  109. Nybo M, Madsen JS. Serious anaphylactic reactions due to protamine sulfate: a systematic literature review. Basic Clin Pharmacol Toxicol 2008; 103:192.
  110. Kober BJ, Scheule AM, Voth V, et al. Anaphylactic reaction after systemic application of aprotinin triggered by aprotinin-containing fibrin sealant. Anesth Analg 2008; 107:406.
  111. Dietrich W, Ebell A, Busley R, Boulesteix AL. Aprotinin and anaphylaxis: analysis of 12,403 exposures to aprotinin in cardiac surgery. Ann Thorac Surg 2007; 84:1144.
  112. Ebo DG, Goossens S, Opsomer F, et al. Flow-assisted diagnosis of anaphylaxis to hyaluronidase. Allergy 2005; 60:1333.
  113. Quhill F, Bowling B, Packard RB. Hyaluronidase allergy after peribulbar anesthesia with orbital inflammation. J Cataract Refract Surg 2004; 30:916.
  114. Eberhart AH, Weiler CR, Erie JC. Angioedema related to the use of hyaluronidase in cataract surgery. Am J Ophthalmol 2004; 138:142.
  115. Borchard K, Puy R, Nixon R. Hyaluronidase allergy: a rare cause of periorbital inflammation. Australas J Dermatol 2010; 51:49.
  116. Delaere L, Zeyen T, Foets B, et al. Allergic reaction to hyaluronidase after retrobulbar anaesthesia: a case series and review. Int Ophthalmol 2009; 29:521.
  117. Ue KL, Kasternow B, Wagner A, et al. Sugammadex: An emerging trigger of intraoperative anaphylaxis. Ann Allergy Asthma Immunol 2016; 117:714.
  118. Nakanishi T, Ishida K, Utada K, et al. Anaphylaxis to sugammadex diagnosed by skin prick testing using both sugammadex and a sugammadex-rocuronium mixture. Anaesth Intensive Care 2016; 44:122.
  119. Baldo BA, McDonnell NJ, Pham NH. Drug-specific cyclodextrins with emphasis on sugammadex, the neuromuscular blocker rocuronium and perioperative anaphylaxis: implications for drug allergy. Clin Exp Allergy 2011; 41:1663.
  120. Menéndez-Ozcoidi L, Ortiz-Gómez JR, Olaguibel-Ribero JM, Salvador-Bravo MJ. Allergy to low dose sugammadex. Anaesthesia 2011; 66:217.
  121. Fisher MM, More DG. The epidemiology and clinical features of anaphylactic reactions in anaesthesia. Anaesth Intensive Care 1981; 9:226.
  122. Fisher M. Anaphylaxis to anaesthetic drugs. Novartis Found Symp 2004; 257:193.
  123. Gouel-Chéron A, Neukirch C, Aubier B, et al. Anaphylactic bronchospasm during general anesthesia is not related to asthma. Allergy 2015; 70:453.
  124. Bridgman DE, Clarke R, Sadleir PH, et al. Systemic mastocytosis presenting as intraoperative anaphylaxis with atypical features: a report of two cases. Anaesth Intensive Care 2013; 41:116.
  125. Laxenaire MC, Mertes PM, Groupe d'Etudes des Réactions Anaphylactoïdes Peranesthésiques. Anaphylaxis during anaesthesia. Results of a two-year survey in France. Br J Anaesth 2001; 87:549.
  126. Jacobsen J, Secher NH. Slowing of the heart during anaphylactic shock. A report of five cases. Acta Anaesthesiol Scand 1988; 32:401.
  127. Laxenaire MC, Mouton C, Frédéric A, et al. [Anaphylactic shock after tourniquet removal in orthopedic surgery]. Ann Fr Anesth Reanim 1996; 15:179.
  128. Anderson A, Eilers H, Yost CS. Anaphylaxis complicating graft reperfusion during orthotopic liver transplantation: a case report. Transplant Proc 2010; 42:1967.
  129. Gibbs NM, Sadleir PH, Clarke RC, Platt PR. Survival from perioperative anaphylaxis in Western Australia 2000-2009. Br J Anaesth 2013; 111:589.
  130. Michalska-Krzanowska G. Tryptase in diagnosing adverse suspected anaphylactic reaction. Adv Clin Exp Med 2012; 21:403.
  131. Laroche D, Gomis P, Gallimidi E, et al. Diagnostic value of histamine and tryptase concentrations in severe anaphylaxis with shock or cardiac arrest during anesthesia. Anesthesiology 2014; 121:272.
  132. Borer-Reinhold M, Haeberli G, Bitzenhofer M, et al. An increase in serum tryptase even below 11.4 ng/mL may indicate a mast cell-mediated hypersensitivity reaction: a prospective study in Hymenoptera venom allergic patients. Clin Exp Allergy 2011; 41:1777.
  133. Guyer AC, Saff RR, Conroy M, et al. Comprehensive allergy evaluation is useful in the subsequent care of patients with drug hypersensitivity reactions during anesthesia. J Allergy Clin Immunol Pract 2015; 3:94.
  134. Ledford DK. Allergy, anaphylaxis and general anesthesia. Immunology Allergy Clin North Am 2001; 21:795.
  135. Kannan JA, Bernstein JA. Perioperative anaphylaxis: diagnosis, evaluation, and management. Immunol Allergy Clin North Am 2015; 35:321.
  136. Siebenhaar F, Weller K, Mlynek A, et al. Acquired cold urticaria: clinical picture and update on diagnosis and treatment. Clin Exp Dermatol 2007; 32:241.