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Department of Anaesthesia and Intensive Care, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia, Australia, john.russell{at}adelaide.edu.au
To the Editor:
The case report (1) on latex anaphylaxis illustrates well the problem of identifying the trigger agent when there are two or more coincidental potential triggers such as, in this report, the administration of an antibiotic and the beginning of surgery.
However, it is important to understand that the anaphylactic reaction is the result of a specific IgE immunoglobulin binding into a receptor site and triggering a cascade. This releases many active agents, including tyrosine kinases, histamine, tryptases, proteoglycans, and leukotrienes (2,3) This process consumes both the IgE and the active agents, which is why at least 4 weeks delay is recommended before the provocative testing of suspected triggering agents (4).
It was therefore disturbing to read that the authors considered that it was "important to convert to a latex-free environment during the resuscitation." This is illogical, as the initial event has almost certainly depleted both the triggering antibody and the vasoactive agents. Any attempt to guess and remove the possible triggers is futile and may interfere with the appropriate treatment.
If a major anaphylaxis occurs, prompt active resuscitation is required. Removing the possible triggers is unnecessary, and even giving more of the triggering agent is not contraindicated, as this is not a phenomenon with a therapeutic dose/response curve, and the associated depletion of the IgE and mast cells means that there will not be any progression of the anaphylactic reaction if additional agent is given. This is a crucial difference from an adverse response with a dose relationship.
References
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