Evaluation of periprocedural hypersensitivity reactions

Ann Allergy Asthma Immunol. 2017 Oct;119(4):349-355.e2. doi: 10.1016/j.anai.2017.07.013. Epub 2017 Aug 31.


Background: Identifying the cause of periprocedural hypersensitivity reactions (HSRs) remains challenging because of the multitude of medications involved. Antibiotics are the most common cause in the United States, whereas neuromuscular blocking agents are most common in Europe.

Objective: To identify causative agents for periprocedural HSRs.

Methods: This study was a 7-year retrospective medical record review of patients evaluated between December 2009 and January 2017 at a drug allergy center in Bronx, New York for periprocedural HSRs, defined as occurring soon before, during, or soon after a medical procedure or operation with or without general anesthesia. Demographics, description of historical HSRs, results of testing to potential causative medications, and tolerance of subsequent anesthesia were reviewed.

Results: Thirty-four patients completed a comprehensive evaluation. Skin testing identified an IgE-mediated cause in 22 patients (64.7%). The most common causative class of medications was induction agents (n = 9 [36%]), with midazolam being the most frequently implicated (n = 6 [3 positive skin test results, 3 equivocal skin test results]). Cefazolin was the most common agent identified (n = 8 [32%]) followed by ondansetron (n = 3 [12%]). Sixteen of 22 contacted patients were exposed to subsequent anesthesia, including 3 patients with negative evaluations. One patient experienced a mild urticarial HSR.

Conclusion: Induction agents were the most common causative agents in our patients, which differs from other studies. Given the variability in evaluations of periprocedural HSRs across the United States with data published on small sample sizes, there is a need to establish national guidelines to standardize evaluations and to create a national registry to allow for data sharing.

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Anesthetics, General / adverse effects*
  • Anesthetics, Intravenous / adverse effects
  • Anti-Bacterial Agents / adverse effects*
  • Cefazolin / adverse effects
  • Drug Hypersensitivity / blood
  • Drug Hypersensitivity / diagnosis*
  • Drug Hypersensitivity / immunology
  • Drug Hypersensitivity / physiopathology
  • Drug Tolerance / immunology*
  • Female
  • Humans
  • Immunoglobulin E / blood
  • Male
  • Midazolam / adverse effects
  • Middle Aged
  • Ondansetron / adverse effects
  • Practice Guidelines as Topic
  • Retrospective Studies
  • Skin Tests


  • Anesthetics, General
  • Anesthetics, Intravenous
  • Anti-Bacterial Agents
  • Immunoglobulin E
  • Ondansetron
  • Cefazolin
  • Midazolam