Finals Mcq Allergy Anaphylaxis

Front 1

AA01 ANZCA
When investigating a patient following anaphylaxis during anaesthesia, the test most widely applicable and least likely to produce false positive results, in identifying the responsible drug or drugs is:

A. skin prick testing

B. I125 radiommunoassay (RIA) to specific circulating IgE

C. RIA inhibition

D. intradermal skin testing

E. assessment of basophil degranulation and histamine release from leukocytes

Back 1

ANSWER A

A. TRUE
Skin prick testing remains the first choice for detection of reactivity.
It has advantages of high sensitivity and specificity, rapid results, flexibility, low cost, good tolerability.
Dermis is pricked with sterile lancets with allergen extract and negative controls - observe for >3mm wheal and flare as mast cells in dermis release histamine (specific IgE to allergen)
The presence of IgE antibody does not prove that the patient is clinically reactive, this needs to be correlated with history. There is small risk for precipitating anaphylaxis

B. FALSE : RAST, although used, it is not most widely used due to high cost and long turn around time.
Radioallergosorbent Test
In vitro test, where radiolabelled antigens react with specific IgE antibodies.
It is used to confirm circulating IgE antigen from Skin Prick Tests. But does not prove IgE cross-linking (Type 1 anaphylaxis)

C. FALSE

D. FALSE : similar sensitivity and specificity to Skin Testing, but carries higher risk of precipitating anaphylaxis.

E. FALSE :
Leucocyte histamine release is available only in specialised labs and has 20% false –ves.
Histamine levels need to be taken within 10-30 minutes and only indicate degranulation, not identify drug

Front 2

AA02 ANZCA Version

Features of anaphylactoid reactions to anaesthetic drugs include:

A. known but rare reactions to inhalational agents

B. a lower frequency of occurrence and severity following pretreatment with H1 and H2 receptor blockers

C. difficulty in establishing that a colloid plasma volume expander is the causative agent

D. rapid synthesis and release of histamine from basophil and mast cell membranes

E. lower morbidity in beta-blocked patients

Back 2

ANSWER C

A. FALSE : inhalational agents have never been shown to cause anaphylaxic/anaphylactoid reactions

B. FALSE : Pretreatment with H1 or H2 antagonists will markedly attenuate severity of anaphylactoid reactions but not frequency.

Arguments/evidence for pretreatment
* reduces histamine-mediated adverse effects in various studies:
* was effective in reducing the incidence of
o opioid-induced anaphylactoid reaction
o adverse effects of non-immune histamine release following muscle relaxant or vancomycin administration.
o anaphylactoid reactions provoked by urea-linked gelatin solutions used as volume expanders, including a prospective study conducted in patients undergoing standard general anaesthesia.
* even in the absence of any well-documented studies concerning anaphylaxis, some authors propose pretreatment with H1, or H1 and H2 antagonists as useful in the management of the patient with a history of anaphylaxis or at risk of non-immune histamine release

Arguments/evidence against:
* beneficial effects have mainly been obtained during clinical manifestations associated with non-immune mediated histamine release. histamine detected during alarming immune-mediated reactions is merely a marker of co-release of more dangerous mediators.
* may blunt the early signs of anaphylaxis, leaving a full-blown episode as the presenting sign.
* Many authors consider that pretreatment with corticosteroids or antihistamines, or both, do not provide for a reliable prevention of immune-mediated reaction.
* proven anaphylactic reactions even in the wake of preoperative H1-H2-receptor antagonists and steroids have been documented in epidemiological surveys.

C. TRUE : by definition, causative agents for anaphylactoid reactions are difficult to isolate as they are non immune mediated. There skin testing and RAST will be un-interpretable as these relay on IgE reactivity.

D. FALSE : synthesis of histamine of slow, taking 4-6 weeks to restore

E. FALSE : can have refractory anaphyaxis with poor response to supportive therapy

Front 3

AA03 ANZCA version

In patients with severe anaphylactoid reaction,

1. previous exposure to the triggering drug is necessary

2. pulmonary oedema is a common clinical finding

3. bronchospasm is the most dangerous feature

4. an aura may precede the acute reaction (if patient awake)

Back 3

ANSWER 4

1. FALSE : don't need prior exposure

2. FALSE :

3. FALSE : circulatory collapse is most dangerous feature

4. TRUE

Front 4

AA04 ANZCA version
Histamine release in anaphylaxis does NOT cause:
A. Tachycardia

B. Myocardial depression

C. Coronary artery vasodilatation

D. Prolonged PR interval

E. Decreased impulse conduction

Back 4

ANSWER B

Histamine is arrythmogenic:
* increased PR
o ventricular irritability
* decreased VF threshold
* shifts in pacemaker site

* H1 via phospholipase C:
o coronary constriction;
o bronchoconstriction;
o slowing at AV node.
o release of prostacyclin
* H2 via cAMP:
o inotropy;
o coronary dilation;
o b'dilation;
o tachy.
o arrythmias
o CNS stimulation
o increased H+ secretion by parietal cells

* Both increase capillary leak. H3 presynaptic.

Front 5

AA05 ANZCA version
In the management of drug-induced anaphylaxis

A. the first priority is the correction of diminished intravascular volume using intravenous colloid

B. adrenaline is contra-indicated in the presence of a ventricular arrhythmia or the concurrent administration of halothane

C. metaraminol is the treatment of choice for hypotension

D. calcium is contra-indicated because of potential enhancement of mediator release

E. lignocaine is the treatment of choice for arrhythmias

Back 5

ANSWER D

A. FALSE: No. Withdraw causative agent. 100% O2. "Fluid therapy should be an early resuscitative measure, but pharmacological resuscitation is the priority" - and in any case adrenaline would be the initial treatment for the hypotension.


B. FALSE: Articles mentions the higher chance of reaction, but it is EXPLICITLY STATED that this should not preclude its use.


C. FALSE Adrenaline is the drug of choice in the management of hypotension, bronchospasm and angio-oedema


D. TRUE "Calcium salts, as inotropes, should be avoided because of the potential enhancement of mediator release"


E. FALSE "Calcium antagonists are probably the drugs of choice, as they are known to antagonize some of the arrhythmogenic effects of histamine in vitro"

Front 6

AA06
Anaphylaxis is least likely in the following situations:

A. Muscle relaxants given to patients with documented IgE antibodies to thiopentone

B. Protamine given to patient on protamine linked insulin

C. Exposure to latex allergy in patient with fruit allergy

D. Women vs men

E. Adults vs neonates

Back 6

ANSWER B

A. FALSE : Antibodies are known to cross-react between muscle relaxants and the pyrimidine nucleus of STP. Specific IgE against quartenary ammonium ions.

B. TRUE : theoretic link, however, no documented evidence of it occurring.

C. FALSE : Latex allergy is indeed more common in those with fruit allergy such as grapefruit allergy, also reported with kiwi fruit, bananas and avocados.

D. FALSE : Females overwhelmingly > males, especially to neuromuscular blockers

E: FALSE : Adults >> neonates

Front 7

AA07 ANZCA version
Recognised features of a true anaphylactic reaction do NOT include

A. Previous exposure to the drug.

B. Mediation by IgE antibody.

C. Histamine relase from mast cells.

D. Activation of the complement system.

E. Intracellular influx of calcium ions.

Back 7

ANSWER D

Activation of complement is not part of Type 1 hypersensitivity reaction.

In anaphylactoid reactions : classical and alternate pathways may be activated particularly after protamine, contrast media, and althesin.

Front 8

AA08
Protamine anaphylaxis more common in:

A. Men who have had vasectomies

B. Infertile women

C. Diabetics taking porcine insulin

D. People with seafood allergy

E. Patients previously exposed to protamine

Back 8

ANSWER E

Protamine sulfate is a polypeptide with molecular weights ranging from 4500 to 5000 Da that is used to reverse heparin anticoagulation and retard the absorption of insulin, often as neutral protamine Hagedorn (NPH). The polypeptide is extracted from salmon milt in a protein purification process. Protamine is a series of arginine-rich basic proteins (also called histones) in fish cell nuclei that provide structural integrity to chromatin.72 The basic guanidine groups of arginine allow it to bind to the acidic heparin molecule to reverse its activity.

A. FALSE : After vasectomy, the blood–testis barrier exposes the tissues, and 55%–73% of men with vasectomies develop antibodies to sperm antigens of this group, 20%–33% develop autoantibodies against protamine. However, there have been no observed clinical reactions in a prospective evaluation of 16 vasectomized patients undergoing cardiac surgery with protamine reversal of heparin, but these were small numbers.

B. FALSE : no documented increase in risk

C. FALSE : no cross reactivity to porcine insulin. However, patients who receive protamine containing insulins, including NPH insulin, are at the greatest risk. Stewart et al. reported in 1984 that 4 of 15 NPH diabetics (27%) had anaphylaxis after protamine reversal of heparin after cardiac catheterization. Incidence of 0.6% (1 of 160) to 2% (1 of 50) in NPH insulin-dependent diabetics undergoing cardiac surgery, a rate 10–30 times more than other patients from 4796 patients evaluated.

D. FALSE : fish-allergic patients are thought to be a theoretical risk. Reports are limited to a hand full of case reports only..

E. True : Previous exposure to IV protamine in vascular or cardiac procedures increase the risk of a reaction on subsequent protamine administration.

Front 9

AA09
Anaphylaxis presents with bronchospasm as SOLE feature in what percent of cases?

A. 50%

B. 30%

C. 15%

D. 5%

E. 0.5%

Back 9

ANSWER D

Front 10

AA10
Latex allergy may present with:

A. Bronchospasm

B. Urticaria

C. Pruritis

D. Pulmonary oedema

E. All of the above

Back 10

ANSWER E

Front 11

AA11 - ANZCA version
In acute anaphylaxis, hypotension results from
1. decreased peripheral resistance
2. hypovolaemia
3. increased venous capacity
4. medullary depression by histamine


Select A if options 1, 2 & 3 are correct
Select B if options 1 & 3 are correct
Select C if options 2 & 4 are correct
Select D if option 4 only is correct
Select E if all options are correct

Back 11

ANSWER B

Front 12

AA12 ANZCA version
In patients giving a history of penicillin allergy

A. cross-sensitvity to cephalosporins occurs in approximately 30% of patients

B. there is an increased liklihood of allergic reactions to neuromuscular blocking drugs

C. beta-lactamase resistant penicillins are less likely to provoke a response

D. a 'test dose' of one tenth the planned dose of penicillin should be given with a 5 minute delay before the main dose

Back 12

ANSWER B

A. FALSE : 8-10% cross reactivity

B. TRUE : patients with penecillin allergy are 3 times more likely to experience anaphylaxis to other drugs

C. FALSE : immunological reaction is against b-lactam ring

D. FALSE : test dose is not given if they are known to be allergic.

Front 13

AA13
Tryptase
1. Is a neutral protease and 99% is located primarily within the mast cell
2. Half-life of 2 to 3 hours
3. A level > 10ng/ml indicates anaphylaxis
4. Must collect blood in lithium heparin tube

Select A if options 1, 2 & 3 are correct
Select B if options 1 & 3 are correct
Select C if options 2 & 4 are correct
Select D if option 4 only is correct
Select E if all options are correct

Back 13

ANSWER A

Tryptase
-is a tetrameric neutral serine protease
-99% in mast cells
-Pro-B-typtase is secreted constitutively and used to measure mast cell number
-mature-B-typtase reflects mast cell activation
-1% in basophils

Tryptase half life 120min
-rise can be quantified as soon as 30 minutes after onset of symptoms
-peak at 120 min, then gradual decay
-back to baseline by 2 days

Tryptase raised in both but anaphylaxis >> anaphylatoid

No raise in tryptase does not exclude an anaphylaxis.

Collection immediately during event, 6 hours post.
Post mortem blood is also suitable if collected within 4 days of death (provided death followed within 30 minutes of the event)

Reference <13 u/ml

Front 14

AA14
The drug LEAST likely to cause bronchospasm and/or anaphylactoid reactions:

A. Protamine

B. Labetalol

C. Esmolol

D. Vancomycin

E. Ketamine

Back 14

ANSWER E

A. FALSE : Histamine release

B. FALSE

C. FALSE

D. FALSE

E. TRUE

Front 15

AA15 ANZCA version Q13

With respect to latex allergy

A. immediate IgE mediated hypersensitivity is thought to be due to polysaccharides retained within finished latex products

B. it is possible to distinguish between contact dermatitis and IgE mediated hypersensitivity on the basis of history

C. no further testing is required if a latex RAST or EAST (enzyme linked) test is positive

D. intradermal tests are used to make a diagnosis, because anaphylaxis has been reported with skin prick testing

E. less than 5% of atopic health workers are likely to skin test positive to latex

Back 15

ANSWER C

LATEX ALLERGY

IgE mediated to natural latex proteins

Incidence : in a Norwegian series, NRL accounts for 3.6% of perioperative anaphylaxis
0.8% non health care workers
5-15% of all health care workers
At risk individuals :
1. genetically predisposed - atopics (Type I - IgE mediated)
2. significant exposure - healthcare workers, children requiring multiple/repetitive surgical and medical interventions (neural tube defects, spinal cord trauma, urogenitial malformations) (delayed Type IV)
**adult spinal cord injuries are not at increased risk

Associated with serological and/or clinical cross-reactivity for numerous plant allergens (banana, chest nut, avocado)

In most patients, diagnosis of NRL anaphylaxis can readily be established with RAST and skin tests.

Front 16

Gasboys
The most appropriate perioperative management of a patient with a history of oral oedema on kiwi fruit exposure is:

(a) increased vigilance for latex allergy

(b) perioperative steroids

(c) preoperative RAST testing for latex allergy

(d) preoperative skin testing for latex allergy

(e) treatment in a latex free environment

Back 16

ANSWER A


Laws P (2008) The clinical implications of latex-fruit allergy Anaesthesia 63 (2), 211–212. doi:10.1111/j.1365-2044.2007.05425

Front 17

Gasboys
The risk of latex allergy is not increased by a history of:

(a) allergy to avocados

(b) allergy to banana

(c) allergy to kiwi fruit

(d) atopy

(e) dandruff

(f) multiple surgical procedures

(g) occupational exposure to latex

Back 17

ANSWER E

Cross reactivity to
avocados
banana
kiwi fruit
tomato
grape
passion fruit
celery
chest nut

Front 18

Gasboys
The prevalence of positive latex skin prick in individuals with increased exposure to latex is about:

(a) 0.056 %

(b) 0.28 %

(c) 1.4 %

(d) 7 %

(e) 35 %

Back 18

ANSWER D

ANZCA/ASA Welfare of Anaesthetists SIG
http://www.anzca.edu.au/ceqa/sig_general/welfare/rd18.htm

Front 19

Gasboys

The prevalence of latex positive latex skin prick in individuals without increased exposure to latex is about:
(a) 0.016 %

(b) 0.08 %

(c) 0.4 %

(d) 2 %

(e) 10 %

Back 19

ANSWER C

ANZCA/ASA Welfare of Anaesthetists SIG

http://www.anzca.edu.au/ceqa/sig_general/welfare/rd18.htm

Front 20

Gasboys
The prevalence of latex positive latex skin prick in atopic individuals without increased exposure to latex is about:

(a) 0.36 %

(b) 1.8 %

(c) 9 %

(d) 50 %

Back 20

ANSWER C

No risks : 0.4%
Increased exposure : 7%
Atopic : 9%
Increased exposure and atopic : 37%

ANZCA/ASA Welfare of Anaesthetists SIG

http://www.anzca.edu.au/ceqa/sig_general/welfare/rd18.htm

Front 21

Gasboys
The prevalence of latex positive latex skin prick in atopic individuals with increased exposure to latex is about:

(a) 0.28 %

(b) 1.4 %

(c) 7 %

(d) 35 %

Back 21

ANSWER D

Front 22

Gasboys
Patients with positive EAST or RAST tests for latex allergy:

(a) do not need confirmatory skin testing

(b) should have confirmatory skin testing

Back 22

ANSWER A

EAST or RAST are specific but not overly sensitive.

Front 23

Gasboys
Anaphylaxis is least likely in the following::

(a) adults

(b) latex exposure in a patient with a
fruit allergy

(c) muscle relaxants given to someone with a documented IgE antibody to thiopentone

(d) protamine given to a patient using protamine insulin

Back 23

ANSWER C

Front 24

The leading cause of anaphylaxis during anaesthesia is:

(a) antibiotics

(b) induction drugs

(c) latex

(d) muscle relaxants

Back 24

ANSWER D

The causes in decreasing order frequency are:
muscle relaxants (70%),
latex (12%),
antibiotics (8%)
induction drugs (4%),
colloids (3%)
and opioids (1.5%)

Front 25

Gasboys

Type I allergic (urticaria, anaphylaxis) reactions to latex are due to the:

(a) chemical addatives

(b) corn starch

(c) latex polysacharides

(d) latex protein

Back 25

ANSWER D

http://www.allergy.org.au/aer/infobulletins/pdf/Latex_Allergy.pdf

Front 26

Gasboys

Type IV allergic reactions (contact dermatitis) to latex are due to the:

(a) chemical additives

(b) corn starch

(c) latex polysacharides

(d) latex protein

Back 26

ANSWER A

http://www.allergy.org.au/aer/infobulletins/pdf/Latex_Allergy.pdf

Front 27

Gasboys

Mastocytosis may result in elevation of serum:

(a) ALT

(b) AST

(c) LDH

(d) creatine kinase

(e) troponin

(f) tryptase

Back 27

ANSWER F

Mastocytosis is a group of rare disorders characterized by presence of mast cell proliferation and accumulation in multiple organs, most commonly the skin

Incidence : less than 1:200,000

Diagnosis :
1 Major and 1 Minor Criteria
OR 3 Minor

Major criterion is multifocal dense infiltrates of mast cells in bone marrow and/or other extracutaneous organs.
Minor criteria include
-baseline total tryptase level of greater than 20 ng/mL
-greater than 25% of the mast cells in bone marrow aspirate smears or tissue biopsy sections having spindle atypical morphology
-mast cells in bone marrow, blood, or other lesional tissue expressing CD25 or CD2;
-detection of a codon 816 c-kit point mutation in blood, bone marrow, or lesional tissue

Presentation
Most patients have pruritic cutaneous lesions.
Some patients, especially those with extensive cutaneous disease, experience acute systemic symptoms exacerbated by certain activities or ingestion of certain drugs or foods. Possible systemic symptoms include flushing, headache, dyspnea, wheezing, rhinorrhea, nausea, vomiting, diarrhea, and syncope.
Patients also may have chronic systemic symptoms involving various organ systems.
o Involvement of the skeletal system may be manifested as bone pain or the new onset of a fracture. Long-term exposure to heparin and stem cell factor from degranulated mast cells is believed to put patients at risk for osteoporosis.
o Involvement of the central nervous system may produce neuropsychiatric symptoms, as well as nonspecific changes such as malaise and irritability.
o GI involvement may yield weight loss, diarrhea, nausea/vomiting, and abdominal cramps.
o Cardiovascular effects can include shock, syncope (resulting from vascular dilatation), or angina.
o Anaphylactic reactions to hymenoptera stings may be the first sign of mastocytosis.

Hint 27

Treatment
1. avoid agents that precipitate mediator release, such as aspirin, nonsteroidal anti-inflammatory drugs, codeine, morphine, alcohol, thiamine, quinine, opiates, gallamine, decamethonium, procaine, radiographic dyes, dextran, polymyxin B, scopolamine, and D-tubocurarine
2. H1 and H2 anatgonists
decrease pruritus, flushing, and GI symptoms
3. Oral disodium cromoglycate may ameliorate cutaneous symptoms, such as pruritus, whealing, and flushing, as well as systemic symptoms, such as diarrhea, abdominal pain, bone pain, and disorders of cognitive function.

Front 28

Gasboys

Amniotic fluid embolism is:

(a) associated with elevated serum tryptase

(b) not associated with elevated serum tryptase

Back 28

ANSWER A

A number of reports have described an increase in the tryptase level, suggesting an association with anaphylaxis. Other investigators found normal levels of tryptase but low levels of complement.

Front 29

Gasboys

A negative mast cell tryptase result does:

(a) exclude an allergic basis to a reaction

(b) not exclude an allergic basis to a reaction

Back 29

ANSWER B

This is especially with anaphylaxis following food ingestion

Front 30

Gasboys

For serum tryptase levels, blood should be collected in a:

(a) EDTA tube

(b) Li heparin tube

(c) plain tube

Back 30

ANSWER C

Serum tryptase analysed.

Take three blood tests, each 5 to 10 ml
(i) immediately after the reaction has been treated, and;
(ii) about 1 hour after the reaction;
(iii) about 6 hours or up to 24 h after the reaction

It is essential to state the time on samples (and time from onset of reaction) and record this in the notes.
Separate serum (or plasma) and store at 4degC if the sample can be analysed
within 48 hours. Otherwise store the sample at – 20degC until it can be sent for measurement of serum tryptase.

Front 31

Gasboys

Following anaphylaxis, serum tryptase has a half-life of about:

(a) 0.5 hours

(b) 2 hours

(c) 8 hours

(d) 30 hours

Back 31

ANSWER B

Front 32

Gasboys
Following suspected occurence of anaphylaxis, serum tryptase levels should be taken as soon as possible and at:

(a) 1 day and 7 days after the episode

(b) 1 to 2 hours and 5 to 6 hours after the episode

(c) 10 minutes and 30 minutes after the episode

(d) 4 to 6 hours and 24 to 36 hours after the episode

Back 32

ANSWER B

Front 33

Gasboys

Following severe allergic reactions, serum tryptase is measured to:

(a) confirm that an anaphylactic or anaphylactoid reaction occurred

(b) diferentiate between anaphylactic and anaphylactoid reactions

(c) identify the allergen

Back 33

ANSWER A

Elevated serum tryptase concentrations do not differentiate an anaphylactic from an anaphylactoid reaction, but does confirm one occured

Front 34

AA26 [Aug08] Anaphylaxis, which is wrong:

A. higher incidence in females (females have a higher incidence of anaphylaxis to neuromusclar drugs)

B. cross-reactivity between ??avocados, bananas and latex

C. vecuronium - more likely to cause an anaphylactoid reaction than anaphylaxis

D. 99% within mast cells

E. peak tryptase in 1hr

Back 34

ANSWER C

Steroidal cause anaphylaxis, benzylisoquinoliums cause anaphylactoid.

Front 35

ANZCA Version [Apr 08]
Which of the following statements regarding anaphylactic and anaphylactoid reactions
is FALSE?

A. cross-sensitivity between latex and bananas, chestnuts and avocado has been reported

B. cross-sensitivity of cephalosporins with penicillin is about 8%

C. gelatin solutions used for resuscitation can worsen any reaction

D. reactions to neuromuscular blocking agents are more common in females

E. vecuronium is more likely to cause an anaphylactoid rather than an anaphylactic
reaction

Back 35

ANSWER E

Front 36

AA25 [Jul07] Q148
In regards to anaphalaxis what is INCORRECT,

A. 8% risk cross-reactivity of cephalosporins with penicillin

B. Colloid use in anaphalaxis often makes situation worse (not exact phrasing...)

C. Tryptase elevated post anaphylactic but not anaphylactoid reaction

D. Repeat tryptase at 24 hours

E.

Back 36

ANSWER C

The CEACCP article from Aug 04 answers these questions, it states

A. 8% cross reactivity between cephalosporins and penicillin

B. Colloids can precipitate histamine release and make the situation worse and are recommended to avoid

C. Tryptase is elevated in both- making this option incorrect

D. Collect blood immediately, at 1hr and a third sample between 6 and 24 hrs

Front 37

AA24 ANZCA Version [Jul07]
Investigation of a suspected anaphylactic reaction requires measurement of tryptase
levels. Correct statements regarding tryptase include each of the following EXCEPT

A. 99% of body tryptase is in mast cells

B. a concentration of greater than 20 ng/mL suggests an anaphylactic reaction

C. blood samples should be repeated 24 to 48 hours after the reaction

D. maximum blood concentrations occur within 1 hour of the reaction

E. tryptase concentrations rise after both anaphylactic and anaphylactoid reactions

Back 37

ANSWER C

A - 99% of body tryptase is in mast cells - true

B - concentration >20ng/ml suggests anaphylaxis - true

C - blood samples at 24-48 hours - false - hence the answer as 6-24hrs is best

D - max blood concs within 1 hour - true (perhaps slightly tempered as max conc within 1 hour of degranulation and question says within 1 hour of reaction, but the reaction is due to degranulation of course . . .

E - tryptase up after anaphylaxis and anaphylactoid - true

Front 38

AA23 ANZCA version

Regarding sampling blood for elevated histamine and mast cell tryptase (β−tryptase) levels to confirm a possible anaphylactic reaction, which of the following statements is INCORRECT?

A. a sample for histamine can be taken up to two hours after the event

B. a sample for tryptase can be taken up to six hours after the event

C. a sample for tryptase can be taken up to two days after fatal anaphylaxis

D. tryptase levels can be elevated after amniotic fluid embolism

E. tryptase levels can be normal after clinical anaphylaxis

Back 38

ANSWER A

A. Histmine peaks at 5-15 minutes and returns to baseline in 30 minutes

Causes of a raised tryptase:
* Anaphylaxis
* Asthma/Allergic rhinitis
* Amniotic Fluid Embolism
* SIDS
* Systemic mastocytosis
* Hyper-eosinophic syndrome

Front 39

AA22 ANZCA version

The commonest initial presenting feature in anaphylaxis is

A. coughing

B. desaturation

C. hypotension

D. rash

E. wheeze

Back 39

ANSWER C

A. coughing - false

B. desaturation - false

C. hypotension - true: See Table 1, CEACCP 2004; 4:4(111)

D. rash - false

E. wheeze - maybe

Front 40

AA21 ANZCA Version [2005-Apr] Q146
The risk of latex allergy is increased in all of the following patients EXCEPT those

A. who work in hospitals

B. with chronic urological conditions

C. with food allergy

D. with sarcoidosis

E. with spina bifida

Back 40

ANSWER D

People at increased risk for developing latex allergy include people who have:
* Congenital urologic abnormalities
* A history of multiple surgical procedures
* Intermittent catheterization
* Dental dams for endodontic care
* Atopy, asthma or eczema
* Food allergies to banana, avocado, kiwi or chestnuts

Front 41

AA20 ANZCA Version [2002-Mar] Q138 (Type K)
CORRECT statement(s) regarding anaphylaxis include that:

1. intravenous administration of antigen is more likely to precipitate a severe reaction than oral administration

2. it is worth giving a small dose of antibiotic before the full dose, as the severity of the reaction will be reduced should anaphylaxis occur

3. measurement of mast cell tryptase is useful if the sample is taken within 4 - 6 hours of the reaction

4. the incidence is equal in males and females

Back 41

ANSWER 1 and 3

Front 42

AA19 ANZCA version
When investigating a patient following severe hypotension during anaesthesia, the most specific test to determine if there was no immmunological basis for the hypotension is

A. plasma histamine level

B. total IgE concentration

C. complement activation

D. mast cell typtase

E. specific IgE levels

Back 42

ANSWER D

Front 43

AA18b ANZCA version

Protamine side effects include all except

A. Impaired platelet function

B. Systemic hypertension

C. Pulmonary hypertension

D. Hypotension

E. Anaphylaxis

Back 43

ANSWER B

A. TRUE : Protamine administered IV in the absence of heparin interacts with platelets and proteins, including fibrinogen

B. FALSE : histamine release causing hypotension

C. TRUE : See question above

D. TRUE : Too rapid administration of protamine sulfate may cause severe hypotension and anaphylactoid reactions

E. TRUE : Hypersensitivity reactions and fatal anaphylaxis have been reported

Front 44

AA18c ANZCA version [2003-Apr] Q106

Side-effects of protamine include all of the following except:

A. Anaphylaxis

B. platelet dysfunction

C. Pulmonary hypertension

D. Pulmonary oedema

E. Systemic hypertension

Back 44

ANSWER E

Front 45

Q44 When a reaction to an anaesthetic drug is suspected

A. The single most useful test to confirm a reaction is mast cell tryptase sampled 20-24 hour the event

B. The single most useful test to confirm a reaction is mast cell tryptase sampled 8-12 hours

C. The most valuable test to identify the drug responsible is radioimmunoassay (RAST)

D. The morphine IgE radioimmunoassay is a sensitive and efficient test for the detection of IgE antibodies to neuromuscular blocking drugs

E. The abscence of an elevated mast cell tryptase (sampled at an appropriate time) excludes a Type I hypersensitivity reaction

Back 45

ANSWER D

A. False: When there has been extreme mast cell degranulation, as occurs in systemic anaphylaxis, tryptase levels rise within 1 hour and remain elevated for 4-6 hours. [1] (http://www.haps.nsw.gov.au/edrsrch/edinfo/tryptase.html)

B. False: Serum (clotted sample, eg crossmatch tube) needs to be taken 1-4 hours after onset of reaction. [2] (http://www.usyd.edu.au/su/anaes/anaphylaxis.html)

C. False: Negative mast cell tryptase tests are only rarely associated with positive skin tests and antibody tests. While, if taken at the correct time, they usually mean anaphylaxis has not occurred, a small number of patients who are probably having reactions related to basophils rather than mast cells, will have MCT levels that are not elevated in association with anaphylaxis. The three we have documented all had a convincing clinical history. Unfortunately these few patients mean that MCT levels cannot be used to show that skin testing is unnecessary.

D. Best Answer: (If implying morphine itself, and not some other IgE generated by morphine) Morphine, which has a single substituted ammonium group, avidly binds in vitro to antibodies that react with NMBDs - (see reference below)

E. - From RCPA Manual (http://www.rcpamanual.edu.au/sections/pathologytest.asp?s=33&i=350) on collecting specimens for tryptase analysis: "Post-mortem blood is also suitable, if collected within 4 days of death, provided that death did not follow the event by less than 30 minutes." "A negative result does not exclude an allergic basis especially with anaphylaxis following food ingestion."

Front 46

AA16 ANZCA version [2001-Aug] Q65, [2002-Mar] Q59, [Apr07] Q63
FALSE statements regarding natural rubber latex allergy include

A. sensitivity of skin prick testing is greater than that of specific IgE antibody detection (RAST)

B. signs of Type I hypersensitivity are usually immediate

C. latex antibodies fall in time in a latex free environment

D. the risk factors of frequent exposure and atopy are additive

E. theatre latex aerogens are lowest in the morning

Back 46

ANSWER B

Front 47

March 2007 [75]
Histamine release during anaphylaxis does NOT cause

A. tachycardia

B. decreased myocardial contractility

C. coronary vasodilatation

D. a shift in the cardiac pacemaker site

E. an increased PR interval

Back 47

ANSWER B

Front 48

March 2007 [138]
The most frequently reported cause of mortality associated with transfusion of blood and blood products is

A. anaphylaxis

B. bacterial sepsis

C. haemolytic reaction

D. transfusion associated graft versus host disease

E. Transfusion Related Acute Lung Injury (TRALI)

Back 48

ANSWER E

Complications of blood transfusion – CEACCP Vol 6 Number 6 2006
TRALI is the most common cause of major morbidity and death
after transfusion. It presents as an acute respiratory distresssyndrome (ARDS) either during or within 6 h of transfusion.

Front 49

Aug 2010 [7]
Anaphylaxis to rocuronium. Which is most likely to cause coss-reactivity ?

A. Vecuronium

B. Pancuronium

C. Atracurium

D. Cisatracurium

E. None of the above -cross reactivity too variable to predict

Back 49

ANSWER E

From AAGBI

Cross-sensitivity between different NMBAs is relatively common, probably because they share a quaternary ammonium epitope. If anaphylaxis to an NMBA is suspected, the patient should undergo skin prick testing with all the NMBAs in current use. If a patient demonstrates a positive skin prick test (SPT) to an NMBA, the patient should be warned against future exposure to all NMBAs if possible. If it is mandatory to use an NMBA during anaesthesia in the future, it would seem appropriate to permit the use of an NMBA which has a negative skin test, accepting that a negative skin test does not guarantee that anaphylaxis will not occur.

Front 50

What is the incidence of anaphylaxis to each of the muscle relaxants as reported in FRANCE?

Back 50

Rocuronium 1 : 5,100 patients exposed to rocuronium

Succinylcholine 1 : 5,500 patients exposed to succinylcholine

Vecuronium 1 : 13,000 patients exposed to vecuronium

Pancuronium 1 : 14,700 patients exposed to pancuronium

Mivacurium 1 : 38,200 patients exposed to mivacurium

Atracurium 1: 52,800 patients exposed to atracurium

Cisatracurium 1 : 148,7000 patients exposed to cisatracurium

Front 51

In anaphylaxis during anaesthesia, bronchospasm is the sole feature in approximately:
(a) 0.34 % of cases

(b) 1 % of cases

(c) 3 % of cases

(d) 9 % of cases

(e) 25 % of cases

Back 51

ANSWER C

The most common clinical features of anaphylaxis during anaesthesia are
cardiovascular (73.6%),
cutaneous (69.6%),
bronchospasm (44.2%)
cardiovascular collapse (53.7%),
angio-oedema (11.7%),
arterial hypotension (17.8%), bradycardia (2.1%)
and cardiac arrest (4%).

Cardiovascular collapse was the sole feature in 8.4%
hypotension in 2%,
bronchospasm in 3.1%
and cutaneous symptoms in 7% cases.

Front 52

Patients with a history of anaphylaxis to penicillin should not receive:

(a) ciprofloxaxin

(b) clindamycin

(c) gentamicin

(d) imipenem

(e) metronidazole

(f) vancomycin

Back 52

ANSWER D

In patients with a history of a rash, the rate of cross-reactivity with cephalosporins is about 2-5%. However, in patients with a history of anaphylaxis to penicillins extreme caution is required with all β-lactams such as cephalosporins and carbepenems.

Front 53

Handling of hydatid cysts can lead to:
(a) DIC

(b) anaphylaxis

(c) bradycardia

(d) haemolysis

(e) pulmonary hypertension

Back 53

ANSWER B

Rupture of the cysts during excision releases highly antigenic 'scolices' necessitating treatment with adrenaline and steroids.

Front 54

Gasboys
Spinal anaesthesia:

(a) decreases the severity of intraoperative anaphylaxis

(b) increases the severity of intraoperative anaphylaxis

Back 54

ANSWER B

http://www.aagbi.or/pdf/Anaphylaxis.pdf