/practice/journal-club / 2018
NAP6: UK Perioperative Anaphylaxis Registry
Cook TM et al. Anaesthesia, surgery, and life-threatening allergic reactions: epidemiology and clinical features (NAP6). Br J Anaesth 2018;121:159-171.
anaphylaxis · registry · drug-allergy
Hook
Antibiotics + NMBs cause most perioperative anaphylaxis; rocuronium leads in many series.
Population, Intervention, Comparison, Outcome
- Population
- 266 cases of Grade 3-5 perioperative anaphylaxis collected over 1 year across the UK NHS.
- Intervention
- Observational — drug exposures, presenting features, treatments documented.
- Comparison
- n/a — descriptive epidemiology.
- Outcome
- Trigger drug attribution, presenting signs, time-to-treatment, mortality.
Methods
Prospective national registry across 342 UK hospitals over 12 months. Cases referred for tryptase + skin testing for drug attribution. Multidisciplinary review for inclusion.
Findings
- Antibiotics: 47% of cases (teicoplanin + co-amoxiclav prominent).
- NMBs: 33% (succinylcholine + atracurium more than rocuronium in UK practice — different profile from French GERAP data).
- Chlorhexidine: 9%.
- Patent blue dye: 5%.
- Mortality: 3.5% — concentrated in delayed recognition + delayed epinephrine.
- Hypotension was the presenting sign in ~47%; bronchospasm in ~18%; rash in only ~50% (often missed under drapes).
Clinical takeaway
Suspect anaphylaxis in unexplained intraoperative hypotension regardless of rash. Give epinephrine FIRST (50-100 mcg IV bolus, repeat or infuse 0.05-0.1 mcg/kg/min); fluid 1-2 L; H1 + H2 + steroid as adjuncts. Tryptase at 1-2 hr + 24 hr confirms diagnosis. Refer all suspected cases to allergist for drug skin testing — never label a drug 'allergy' on a chart without confirmation, but never re-expose without skin testing if the index event was Grade 3+.
Limitations
- UK-specific drug exposure patterns (teicoplanin > vancomycin; rocuronium less prominent than in France).
- Reliance on referral may underestimate incidence.
- Skin testing has imperfect sensitivity; some attributions are presumptive.
Discussion questions
- Does your facility have a perioperative anaphylaxis pathway including tryptase timing + allergist follow-up?
- How do you handle the patient with 'PCN allergy' on chart — do you skin-test before re-exposure or default to vancomycin?
- Are you confident your drape-up workflow doesn't hide an evolving rash for 30+ minutes?