Neuromuscular blocking agent drug challenge: a literature review and protocol proposal with biological evaluation.

IF 4.2 2区 医学 Q1 ANESTHESIOLOGY
European Journal of Anaesthesiology Pub Date : 2024-10-01 Epub Date: 2024-06-24 DOI:10.1097/EJA.0000000000002033
Aurélie Gouel-Chéron, Catherine Neukirch, Sylvie Chollet-Martin, Arnaud Valent, Benoit Plaud, Dan Longrois, Pascale Nicaise-Roland, Philippe Montravers, Luc de Chaisemartin
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引用次数: 0

Abstract

Background: Drug challenge is the gold standard for identifying causative agents of drug allergies. Although clinical guidelines have recently been published, they do not recommend neuromuscular blocking agent (NMBA) drug challenges. NMBA challenges are rendered difficult by the lack of homogeneity of routine allergy work-ups and the necessity of a specialised setting. Several scenarios support NMBA challenges, such as an ambiguous allergy work-up, a high suspicion of a false-positive skin test or identification of a well tolerated alternative NMBA strategy. Furthermore, routine allergy work-ups may not recognise non-IgE mechanisms, such as IgG or MRGPRX2, whereas drug challenges may reveal them. Finally, if the culprit NMBA is not identified, subsequent anaesthesia regimens will be challenging to implement, resulting in increased risk.

Objectives: This literature review discusses the indications, strategies, doses, monitoring methods, limitations, and unresolved issues related to drug challenges for NMBAs.

Design: The literature review included randomised controlled trials, observational studies, reviews, case reports, series, and comments on humans.

Data sources: Studies were retrieved from databases (PubMed) and electronic libraries (OVID, EMBASE, Scopus, etc.).

Eligibility criteria: All studies that referred to the NMBA challenge were included without publication date limitations.

Results: NMBA challenge may be considered in NMBA anaphylaxis patients with inconclusive or ambivalent IgE diagnostic work-up under controlled conditions (presence of anaesthetists and allergists with continuous monitoring in a secured environment). To illustrate its utility, a case report of a double NMBA challenge in a patient with NMBA cross-reactivity is presented, along with biological explorations to detect subclinical cellular activation, a novel aspect of this procedure.

Conclusion: Drug challenges could be implemented during the NMBA allergy work-up under strict safety conditions at specialised centres with close collaboration between anaesthetists and allergists. This could decrease uncertainty and contribute to defining a safer strategy for subsequent anaesthetic drug regimens.

神经肌肉阻断剂药物挑战:文献综述和生物评估方案建议。
背景:药物挑战是确定药物过敏致病因子的黄金标准。虽然最近发布了临床指南,但其中并未推荐神经肌肉阻断剂(NMBA)药物挑战。由于常规过敏检查缺乏同质性,且必须在专门的环境中进行,因此 NMBA 药物试验变得十分困难。有几种情况支持 NMBA 药物挑战,如过敏检查结果不明确、高度怀疑皮试假阳性或确定了耐受性良好的 NMBA 替代策略。此外,常规过敏检查可能无法识别 IgG 或 MRGPRX2 等非 IgE 机制,而药物挑战可能会发现这些机制。最后,如果未识别出罪魁祸首 NMBA,后续麻醉方案的实施将面临挑战,从而导致风险增加:本文献综述讨论了与 NMBA 药物挑战相关的适应症、策略、剂量、监测方法、局限性和未解决的问题:文献综述包括随机对照试验、观察性研究、综述、病例报告、系列研究以及对人类的评论:数据来源:从数据库(PubMed)和电子图书馆(OVID、EMBASE、Scopus 等)检索研究:所有提及 NMBA 挑战的研究均被纳入,无出版日期限制:结果:在可控条件下(麻醉师和过敏症专家在场,并在安全的环境中进行持续监测),对于 IgE 诊断不确定或不明确的 NMBA 过敏性休克患者,可以考虑进行 NMBA 挑战。为了说明该方法的实用性,本文介绍了对一名 NMBA 交叉反应患者进行双重 NMBA 挑战的病例报告,以及检测亚临床细胞活化的生物学探索,这是该程序的一个新方面:结论:在麻醉师和过敏学家密切合作的情况下,可在专业中心严格的安全条件下,在 NMBA 过敏检查过程中实施药物挑战。这可以减少不确定性,有助于为后续的麻醉药物方案确定更安全的策略。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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来源期刊
CiteScore
6.90
自引率
11.10%
发文量
351
审稿时长
6-12 weeks
期刊介绍: The European Journal of Anaesthesiology (EJA) publishes original work of high scientific quality in the field of anaesthesiology, pain, emergency medicine and intensive care. Preference is given to experimental work or clinical observation in man, and to laboratory work of clinical relevance. The journal also publishes commissioned reviews by an authority, editorials, invited commentaries, special articles, pro and con debates, and short reports (correspondences, case reports, short reports of clinical studies).
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