围术期过敏反应天津课件

,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,Company Logo,*,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,Company Logo,*,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,Company Logo,*,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,Company Logo,*,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,Company Logo,*,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,Company Logo,*,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,Company Logo,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,2020/9/14,#,病例汇报,M,，,56,岁，拟行颈内动脉剥脱术。,ASA,分级,。全身麻醉，诱导过程顺利。予琥珀酰明胶短时间内，血压突然下降,80/40 mmHg,，予苯肾及麻黄素无反应，很快出现室颤。,CPR45min,后恢复自主窦性心律。,揭开手术单发现患者皮肤,出现,血管性水肿,。,取消手术，带气管导管返,ICU,。,病例汇报M，56岁，拟行颈内动脉剥脱术。ASA分级。,问题的提出,究竟发生了什么情况？,如何识别？正确处理？,如何预防？,问题的提出究竟发生了什么情况？,牛顿苹果的故事,牛顿苹果的故事,文献查阅,Fisher MM,Baldo BA.The incidence and clinical features of anaphylactic reactions during anesthesia in Australia.,Annales Francaises dAnesthesie et de Reanimation 1993;12:,97104.,Laxenaire MC.Epidemiology of anesthetic anaphylactoid reactions.Fourth multicenter survey(July 1994-December,1996).Annales Francaises dAnesthesie et de Reanimation 1999;,18:796809.,Laxenaire MC,Mertes PM.Anaphylaxis during anaesthesia.Results of a two-year survey in France.British Journal of Anaesthesia 2001;87:54958.,Association of Anaesthetists of Great Britain and Ireland.Suspected anaphylactic reactions associated with anaesthesia,London,2003.,http:/www.aagbi.org/pdf/Anaphylaxis.pdf,文献查阅Fisher MM,Baldo BA.The i,围术期过敏反应的特殊性,围术期用药,复杂,临床特征,需鉴别,快速诊断方法,尚缺乏,围术期过敏反应的特殊性围术期用药,定义,过敏反应,是一种严重的，危及生命的，全身性或系统性速发型超敏反应。,Anaphylaxis,is a severe,life-threatening,generalized or systemic hypersensitivity reaction.,定义过敏反应,型,型,型,型,速发型变态反应,细胞毒型变态反应,免疫复合物型变态反应,迟发型变态反应,定义,超敏反应,也称变态反应，是指机体对某些抗原初次应答后，再次接受相同抗原刺激时，发生的一种以机体生理功能紊乱或组织细胞损伤为主的特异性免疫应答。,型型型型速发型变态反应细胞毒型变态反应免疫复合物型变,定义,由,IgE,介导的反应,过敏反应,非,IgE,介导的反应,2008,版,定义由IgE介导的反应过敏反应非IgE2008版,诊断,临床、生物学、变态反应学证据,三要素,CAST,既往史,及,临床表现,血清类胰蛋白酶,RAST,诊断,皮肤试验,诊断临床、生物学、变态反应学证据CAST既往史血清类胰蛋白酶,既往病史,危险因素,对鸡蛋,/,大豆乳剂过敏,明胶过敏,既往全身麻醉后过敏史,多种药物过敏综合征,既往全麻史,全麻过敏的家族史,对化妆品过敏,Liccardi G,Lobefalo G,Di Florio E,et al.Strategies for the prevention of,asthmatic,anaphylactic and anaphylactoid reactions during the administration,of anesthtics and/or contrast media.Investig Allergol Clin Immunol 2008;18:1-11,.,可能过敏原,丙泊酚,人工代血浆制品,所有药物,所有药物,肌松药,所有药物,肌松药,既往病史危险因素对鸡蛋/大豆乳剂过敏明胶过敏既往全身麻醉后过,临床表现,Scandinavian Clinical Practice Guidelines on the diagnosis,management and follow-up of anaphylaxis during anaesthesia.,Acta Anaesthesiol Scand.,2007Jul;51(6):655-70.,临床表现Scandinavian Clinical Prac,propofol-induced,anaphylaxis,Allergy Asthma Immunol Res.,2012 Jan;4(1):46-8.,A case of propofol-induced oropharyngeal angioedema and bronchospasm.,You BC,Jang AS,Han JS,Cheon HW,Park JS,Lee JH,Park SW,Kim DJ,Park CS,.Korea.,a 74-year-old woman who had an anaphylactic reaction with severe,oropharyngeal edema,and,bronchospasm,for a few minutes after receiving,propofol,during,endoscopic examination,.An,allergy skin test was positive for both propofol and soybean.,Soybean in the intralipid is one component of propofol,and we,concluded that this anaphylaxis was caused by soybean.,propofol-induced anaphylaxisAl,临床表现,皮肤粘膜,皮肤潮红,各种皮疹（尤其是大风团样丘疹）,皮下血管神经性水肿,全身皮肤粘膜水肿,注：,1,、往往是严重过敏反应最早且最常（,80%,）出现的征兆。,2,、仅有皮肤表现并不能诊断为严重过敏反应。,临床表现皮肤粘膜注：,呼吸系统,唾液及痰液分泌增多,喉痉挛,支气管痉挛,肺内出现哮鸣音及湿啰音,口咽部水肿、喉水肿,最多见的表现之一，也是最主要的死因。,呼吸系统最多见的表现之一，也是最主要的死因。,心血管系统,不明原因、迅速出现低血压,心动过速,严重心律失常,循环衰竭,在,10.5%,病例中，心血管表现为唯一特征。,Laxenaire M,et al.Anaphylaxis during anesthesia.Results of 2 years,survey in France.British Journal of Anesthesia,2001;87:549-556.,心血管系统Laxenaire M,et al.Anaph,血清类胰蛋白酶,采集三个时间点,的样本,血清类胰蛋白酶采集三个时间点,皮肤试验,皮肤试验依然是检测,IgE,介导的过敏反应的金标准，主要通过患者皮肤组织的肥大细胞与可疑过敏原接触，观察皮肤反应来完成诊断。,Dewachter P,Mouton-Faivre C:What investigation after an anaphylactic reaction during anaesthesia?Curr Opin Anaesthesiol 2008;21:3638.,皮肤试验皮肤试验依然是检测IgE介导的过敏反应的金标准，主要,皮肤试验,皮肤试验,皮肤试验,皮肤试验,放射性过敏原吸附试验,放射性过敏原吸附试验,放射性过敏原吸附试验,仅有少数,麻醉药物具有商品化的,IgE,测定方法。,放射性过敏原吸附试验仅有少数麻醉药物具有商品化的IgE测定方,放射性过敏原吸附试验,病例组,:,对罗库溴铵过敏的患者,对照组,2,：与神经肌肉阻滞剂无关的麻醉相关过敏反应的患者,对照组,1,：耐受罗库溴铵的无麻醉相关过敏的患者,放射性过敏原吸附试验病例组:对罗库溴铵过敏的患者对照组2：与,嗜碱性粒细胞活化试验,Non-allergic anaphylaxis,Allergic anaphylaxis,嗜碱性粒细胞活化试验Non-allergic anaphyl,嗜碱性粒细胞活化试验,嗜碱性粒细胞活化试验,嗜碱性粒细胞活化试验,嗜碱粒细胞活化,CD63,表达增加,流式细胞术检测,嗜碱性粒细胞活化试验嗜碱粒细胞活化CD63表达增加流式细胞术,处理流程,即刻处理,C,irculation,A,irway,B,reathing,脱离所有可能的过敏原,静脉肾上腺素,Anaesthesia,2009,64,199211.,Acta Anaesthesiol Scand 2007;51:655670