Predictive value of allergy tests for neuromuscular blocking agents: tackling an unmet need
Article first published online: 23 JUL 2014
© 2014 John Wiley & Sons Ltd
Clinical & Experimental Allergy
Volume 44, Issue 8, pages 1069–1075, August 2014
How to Cite
Clinical & Experimental Allergy, 2014 (44) 1069–1075., , , , and ,
- Issue published online: 23 JUL 2014
- Article first published online: 23 JUL 2014
- Accepted manuscript online: 21 MAY 2014 11:38AM EST
- Manuscript Accepted: 13 MAY 2014
- Manuscript Revised: 8 MAY 2014
- Manuscript Received: 17 FEB 2014
- Research Foundation Flanders. Grant Number: 1700614N
- FWO. Grant Number: 1800614N
- provocation test;
- skin test
Neuromuscular blocking agents (NMBAs) are a predominant cause of perioperative anaphylaxis in Europe. Diagnosis of NMBA allergy relies upon the careful review of the anaesthetic report complemented with skin tests. Additional diagnostic tests are quantification of specific IgE antibodies (sIgE) and basophil activation test (BAT). However, data on the predictive value of the skin tests, the BAT and the sIgE assays (drug-specific and substituted ammonium structures) are limited or not available, mainly because such exploration requires dangerous NMBA provocation tests.
In this study, the predictive value of skin test, BAT and measurement of sIgE to substituted ammonium structures is gathered from a review of anaesthetic records of subsequent surgical procedures with NMBA administration and/or occurrence of perioperative incidents.
We investigated a series of 272 patients with perioperative anaphylaxis, of whom 100 had undergone second general anaesthesia. Negative skin test and negative BAT assisted the selection of alternative NMBA, which were well tolerated in all cases. Five patients with a positive sIgE to rocuronium but with negative skin testing and BAT safely received rocuronium during second anaesthesia. Twelve patients with sIgE reactivity to morphine, but negative skin test and BAT to benzylisoquinolines, tolerated administration of cisatracurium or atracurium. Alternatively, benzylisoquinoline allergy went undetected in the morphine solid-phase assay.
Skin test and BAT have an excellent negative predictive value in our series. The uneventful re-exposure of rocuronium in patients with an isolated positive sIgE result to rocuronium calls into question the predictive value of this assay and suggests sIgE serology to be less clinically predictive than the functional investigations relying upon activation of mast cells or basophils. The presence of a positive sIgE to substituted ammonium structures such as morphine does not preclude further use of benzylisoquinolines.