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array:24 [ "pii" => "S2341192923000045" "issn" => "23411929" "doi" => "10.1016/j.redare.2021.09.009" "estado" => "S300" "fechaPublicacion" => "2023-01-01" "aid" => "1381" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "copyrightAnyo" => "2021" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Revista Española de Anestesiología y Reanimación (English Version). 2023;70:17-25" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0034935621002607" "issn" => "00349356" "doi" => "10.1016/j.redar.2021.09.004" "estado" => "S300" "fechaPublicacion" => "2023-01-01" "aid" => "1381" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Rev Esp Anestesiol Reanim. 2023;70:17-25" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">ORIGINAL</span>" "titulo" => "Anafilaxia perioperatoria severa: Incidencia en un hospital terciario en España durante 20 años. Estudio de cohorte histórico" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "17" "paginaFinal" => "25" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Severe perioperative anaphylaxis: Incidence in a tertiary hospital in Spain over a 20-year period. A historical cohort study" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figura 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1116 "Ancho" => 1508 "Tamanyo" => 55486 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Valores de la mediana de triptasa a las 2 h en función del grado de severidad (III-V) de la reacción de anafilaxia.</p> <p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Mediana (cuartil 1; cuartil 3): severidad III: 10,7 (3,9; 19,4); severidad IV: 66,2 (36,9; 113); severidad V: 200 (105; 285).</p> <p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Prueba de Kruskal-Wallis: p < 0,0001</p> <p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Análisis <span class="elsevierStyleItalic">post hoc</span>:</p> <p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">* p entre severidad III y severidad IV = 0,001</p> <p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">** p entre severidad III y severidad V<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.007</p> <p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">*** p entre severidad IV y severidad V = 1.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "F. Escolano, J. Yelamos, L. Moltó, B. Fort, M. Espona, A. Giménez-Arnau" "autores" => array:6 [ 0 => array:2 [ "nombre" => "F." "apellidos" => "Escolano" ] 1 => array:2 [ "nombre" => "J." "apellidos" => "Yelamos" ] 2 => array:2 [ "nombre" => "L." "apellidos" => "Moltó" ] 3 => array:2 [ "nombre" => "B." "apellidos" => "Fort" ] 4 => array:2 [ "nombre" => "M." "apellidos" => "Espona" ] 5 => array:2 [ "nombre" => "A." "apellidos" => "Giménez-Arnau" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2341192923000045" "doi" => "10.1016/j.redare.2021.09.009" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192923000045?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935621002607?idApp=UINPBA00004N" "url" => "/00349356/0000007000000001/v1_202212270537/S0034935621002607/v1_202212270537/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2341192923000057" "issn" => "23411929" "doi" => "10.1016/j.redare.2021.09.010" "estado" => "S300" "fechaPublicacion" => "2023-01-01" "aid" => "1393" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Revista Española de Anestesiología y Reanimación (English Version). 2023;70:26-36" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Special article</span>" "titulo" => "Result of the implementation of a quality management system based on the ISO 9001:2015 standard in a surgical intensive care unit" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "26" "paginaFinal" => "36" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Resultado de la implementación de un sistema de gestión de la calidad en base a la Norma ISO 9001:2015 en una unidad de cuidados intensivos quirúrgica" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1488 "Ancho" => 2500 "Tamanyo" => 295230 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0120" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Representation of the structure of the ISO 9001:2015 Standard with the Plan-Do-Check-Act cycle of the Surgical ICU during the years 2017–2018.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M. Mercader Alarcón, J. Miralles Sancho, A. Pérez Carbonell, V. Nolasco Guirao, M.A. Antón Latour, M.M. Miras García" "autores" => array:6 [ 0 => array:2 [ "nombre" => "M." "apellidos" => "Mercader Alarcón" ] 1 => array:2 [ "nombre" => "J." "apellidos" => "Miralles Sancho" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Pérez Carbonell" ] 3 => array:2 [ "nombre" => "V." "apellidos" => "Nolasco Guirao" ] 4 => array:2 [ "nombre" => "M.A." "apellidos" => "Antón Latour" ] 5 => array:2 [ "nombre" => "M.M." "apellidos" => "Miras García" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0034935621002887" "doi" => "10.1016/j.redar.2021.09.013" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935621002887?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192923000057?idApp=UINPBA00004N" "url" => "/23411929/0000007000000001/v1_202302161340/S2341192923000057/v1_202302161340/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2341192923000069" "issn" => "23411929" "doi" => "10.1016/j.redare.2021.09.011" "estado" => "S300" "fechaPublicacion" => "2023-01-01" "aid" => "1400" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Revista Española de Anestesiología y Reanimación (English Version). 2023;70:10-6" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>" "titulo" => "Nasal/orotracheal tube switch to reduce length of mechanical ventilation in neurocritical patients: A propensity score matched analysis" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "10" "paginaFinal" => "16" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Sustitución del tubo nasal/orotraqueal para reducir la duración de la ventilación mecánica en pacientes neurocríticos: análisis de emparejamiento por puntuación de propensión" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1190 "Ancho" => 2091 "Tamanyo" => 126862 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0035" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Flow diagram of the study.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. De Cassai, G. Andreatta, P. Diana, F. Geraldini, L. Pasin, M. Salvagno, G. Panciera, P. Navalesi, M. Munari" "autores" => array:9 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "De Cassai" ] 1 => array:2 [ "nombre" => "G." "apellidos" => "Andreatta" ] 2 => array:2 [ "nombre" => "P." "apellidos" => "Diana" ] 3 => array:2 [ "nombre" => "F." "apellidos" => "Geraldini" ] 4 => array:2 [ "nombre" => "L." "apellidos" => "Pasin" ] 5 => array:2 [ "nombre" => "M." "apellidos" => "Salvagno" ] 6 => array:2 [ "nombre" => "G." "apellidos" => "Panciera" ] 7 => array:2 [ "nombre" => "P." "apellidos" => "Navalesi" ] 8 => array:2 [ "nombre" => "M." "apellidos" => "Munari" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0034935621002966" "doi" => "10.1016/j.redar.2021.09.015" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935621002966?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192923000069?idApp=UINPBA00004N" "url" => "/23411929/0000007000000001/v1_202302161340/S2341192923000069/v1_202302161340/en/main.assets" ] "en" => array:21 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>" "titulo" => "Severe perioperative anaphylaxis: Incidence in a tertiary hospital in Spain over a 20-year period. A historical cohort study" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "17" "paginaFinal" => "25" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "F. Escolano, J. Yelamos, L. Moltó, B. Fort, M. Espona, A. Giménez-Arnau" "autores" => array:6 [ 0 => array:4 [ "nombre" => "F." "apellidos" => "Escolano" "email" => array:1 [ 0 => "fescolano@parcdesalutmar.cat" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "J." "apellidos" => "Yelamos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "L." "apellidos" => "Moltó" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "B." "apellidos" => "Fort" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "M." "apellidos" => "Espona" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 5 => array:3 [ "nombre" => "A." "apellidos" => "Giménez-Arnau" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital del Mar, Instituto Municipal de Investigación Médica (IMIM-Hospital del Mar), Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Patología, Laboratorio de Inmunología, Hospital del Mar, Instituto Municipal de Investigación Médica (IMIM-Hospital del Mar), Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Farmacia, Hospital del Mar, Instituto Municipal de Investigación Médica (IMIM-Hospital del Mar), Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital del Mar, Instituto Municipal de Investigación Médica (IMIM-Hospital del Mar), Barcelona, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Anafilaxia perioperatoria severa: Incidencia en un hospital terciario en España durante 20 años. Estudio de cohorte histórico" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1116 "Ancho" => 1508 "Tamanyo" => 65030 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0165" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Median tryptase levels at 2<span class="elsevierStyleHsp" style=""></span>h as a function of the degree of severity (III–V) of the anaphylaxis.</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Median (quartile 1; quartile 3): severity III: 10.7 (3.9; 19.4); severity IV: 66.2 (36.9; 113); severity V: 200 (105; 285).</p> <p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Kruskal-Wallis test: <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.0001.</p> <p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Post hoc analysis:</p> <p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">* <span class="elsevierStyleItalic">P</span> between severity III and severity IV<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.001.</p> <p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">** <span class="elsevierStyleItalic">P</span> between severity III and severity V<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.007.</p> <p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">*** <span class="elsevierStyleItalic">P</span> between severity IV and severity V<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>1.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Anaphylaxis is defined as a severe systemic hypersensitivity reaction of rapid onset and life-threatening severity that requires life-saving treatment. The incidence of moderate to severe perioperative anaphylaxis ranges from 1/6000 to 1/13,000 anaesthetic events<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–5</span></a>, with mortality between 3%–9%<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3,5,6</span></a>.</p><p id="par0010" class="elsevierStylePara elsevierViewall">It is difficult to identify the aetiological agent due to the large number of drugs administered during the perioperative period. In epidemiological studies conducted in France<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>, Australia<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>, England<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,7,8</span></a>, and the USA<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>, 48%–72% of reactions occurring during anaesthesia are IgE-mediated. The most frequently identified substances are: neuromuscular blockers (NMB) (11%–58%), antibiotics (8%–67%), latex (16%–19%), hypnotics (.8%–17%), and colloids (2%–4%)<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3,7–10</span></a>.</p><p id="par0015" class="elsevierStylePara elsevierViewall">There are few epidemiological studies in Spain and they include a small number of patients. The overall incidence of anaphylaxis ranges from 1/1210 to 1/10,000 anaesthesias and the most frequently identified agents are antibiotics (20%–44%), NMB (11%–37%), non-steroidal analgesics (NSAIDs) (4.1%–26%), and latex (2%–13%)<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,11,12</span></a>.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The main objective of this study was to determine the incidence of severe perioperative anaphylactic reactions and to describe the demographic, aetiological, and clinical characteristics, therapeutic management, and progression of the episodes. Determining the usefulness of tryptase and histamine, and specific IgE and skin tests in identifying the aetiological agent. The secondary objective was to identify possible risk factors associated with the degree of severity of the episode.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">Historical cohort study. Severe anaphylaxis reactions occurring in a tertiary public hospital in Spain were studied over a 20-year period (1 January 1997–31 December 2016). Patients undergoing general or locoregional anaesthesia, or sedation for elective or emergency surgery in all surgical specialties except cardiac and paediatric surgery were included. The severity of perioperative anaphylaxis was graded using a five-level scale<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> and classes III to V were considered severe anaphylaxis. Class III indicates the presence of severe life-threatening symptoms, including cardiovascular collapse, tachycardia or bradycardia, cardiac arrhythmias, or bronchospasm; class IV: cardiac or respiratory arrest; and class V: death.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The hospital’s clinical research ethics committee (ref. 2017/7236/l) approved the study. Informed consent was obtained from the patients who agreed to undergo the subsequent diagnostic studies (skin and specific IgE tests).</p><p id="par0035" class="elsevierStylePara elsevierViewall">In cases of suspected severe anaphylaxis, the anaesthesiologist activated the diagnostic protocol (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), which included drawing blood samples during the first 15<span class="elsevierStyleHsp" style=""></span>min to measure plasma histamine levels (radioimmunoassay, Immunotech s.r.o., Prague, Czech Republic), at 2<span class="elsevierStyleHsp" style=""></span>h, 6<span class="elsevierStyleHsp" style=""></span>h, and 24<span class="elsevierStyleHsp" style=""></span>h to determine serum tryptase levels (fluoroenzyme immunoassay, CAP System, Phadia AB, Uppsala, Sweden), and at four to eight weeks to detect IgE antibodies specific for latex and drugs available in our laboratory (antibiotics, NSAIDs, and local anaesthetics) (radioallergosorbent assay, Immunolab GmbH, Kassel, Germany). Serum tryptase levels<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>13<span class="elsevierStyleHsp" style=""></span>μg<span class="elsevierStyleHsp" style=""></span>L<span class="elsevierStyleSup">−1</span> and plasma histamine levels<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>.1<span class="elsevierStyleHsp" style=""></span>μg<span class="elsevierStyleHsp" style=""></span>dL<span class="elsevierStyleSup">−1</span> were considered positive.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">If a patient underwent two or more surgeries during the study period, each anaesthetic was considered a new exposure.</p><p id="par0045" class="elsevierStylePara elsevierViewall">A specific electronic medical record system was used to record patient characteristics (age, sex), history of atopy and allergies, associated pathologies and the treatment the patient had been receiving, physical condition (ASA classification), drugs administered with their chronological sequence, clinical picture, severity, treatment administered, and progression of the anaphylaxis. Treatment was administered according to the anaesthesiologist's judgement. After four to eight weeks, the attending physician referred the patients to the dermatology department, where skin tests (prick test and intradermal tests) were performed for drugs administered during anaesthesia and latex and specific IgE levels were determined to identify the causative agent. The aetiological study included surviving patients >18 years of age with severity III or higher. Patients who did not sign informed consent for testing or who had uncontrolled severe disease or immunosuppression that made the study inadvisable were excluded (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">The hospital pharmacy prepared allergen extracts for skin testing using commercial drug preparations diluted in saline. For skin and intradermal testing, drug concentrations were based on our protocol<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and published consensus protocols<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14,15</span></a>. Patients were instructed to avoid any drugs that could interfere with skin reactivity for one week before the day of testing. An experienced dermatologist performed skin testing. A positive control (10<span class="elsevierStyleHsp" style=""></span>mg<span class="elsevierStyleHsp" style=""></span>mL<span class="elsevierStyleSup">−1</span> histamine) was used for the prick test and a negative control (.9% normal saline solution) for both the prick test and the intradermal test. Results were evaluated 15–20<span class="elsevierStyleHsp" style=""></span>min after the test and were considered positive for the prick test if the diameter of the allergen papule was 3<span class="elsevierStyleHsp" style=""></span>mm larger compared to the negative control. An intradermal test was considered positive if the size of the papule increased by more than 3<span class="elsevierStyleHsp" style=""></span>mm in diameter from the initial papule and it was accompanied by surrounding erythema. In case of positivity to any neuromuscular blocker, other NMB were studied because of the risk of cross-reactivity. All patients underwent a latex prick test.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Perioperative reactions were considered to be those occurring between admission to the operating theatre and discharge from the post-anaesthesia recovery unit (PACU).</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Statistical analysis</span><p id="par0060" class="elsevierStylePara elsevierViewall">Continuous variables are expressed as percentages (%), or by median and interquartile range. Categorical variables are expressed as cases and percentages. For univariate analysis, the χ<span class="elsevierStyleSup">2</span> test and Fisher's exact test were used for qualitative variables, and the Kruskal-Wallis test and Mann-Whitney U test for quantitative variables. The relationship of categorised tryptase (greater than or equal to 13<span class="elsevierStyleHsp" style=""></span>μg<span class="elsevierStyleHsp" style=""></span>L<span class="elsevierStyleSup">−1</span>) with the type of reaction (IgE-mediated vs. non-IgE-mediated) was studied using binary logistic regression: univariate and multivariate analysis (adjusted for sex and age). SPSS v.22.0 (IBM Corp., Armonk, NY) was used for the calculations, with a statistical significance level of <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.05.</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><p id="par0065" class="elsevierStylePara elsevierViewall">During the study period, 288,594 anaesthetic procedures were performed. We observed 66 reactions with a severity equal to or greater than class III (1 case per 4373 procedures) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). In 39 cases (59.1%), these occurred in men. The mean age was 60.8<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>17.3 (range, 17–89 years). Twenty-four (36.4%) of the patients had a history of drug allergy, 16 (24.2%) of atopy, and 6 (9.1%) of food allergy. Physical status was as follows: ASA I: 6.1%; ASA II: 30.3%; ASA III: 56.1% and ASA IV: 7.6%.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Symptoms were cardiovascular in 86.4% of patients, respiratory in 72.7%, mucocutaneous in 56.1%, and digestive in 24.2% (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). In 55 cases (83.3%), the reactions were classified as class III, in eight (12.1%) as class IV, and in three (4.5%) as class V. In 59 (89.4%) patients the manifestations were immediate and in 7 (10.6%) semi-delayed. All patients required treatment, 81.8% with vasoactive drugs (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). Three (4.5%) of the patients died.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">In 39 (59.1%) patients, reactions occurred after induction of anaesthesia and before surgery; in 14 (21.2%) during the PACU stay; in 10 (15.2%) during surgery; and in three (4.5%) during reversal of anaesthesia.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Serum tryptase and/or plasma histamine levels were measured immediately in 63 (95.5%) patients. Tryptase drawn at two hours was positive in 31 (53.4%) of 58 patients and negative in 27. Histamine, drawn during the first 15<span class="elsevierStyleHsp" style=""></span>min of the reaction, was positive in 22 (50%) of 44 patients. There was a significant correlation between reaction severity and serum tryptase level at 2<span class="elsevierStyleHsp" style=""></span>h (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.0001) (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>) and at 6<span class="elsevierStyleHsp" style=""></span>h after reaction onset (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.026). In three patients it was not possible to perform the tryptase study at 6<span class="elsevierStyleHsp" style=""></span>h and 24<span class="elsevierStyleHsp" style=""></span>h due to immediate death. We did not observe significant associations between the degree of severity of the reaction and plasma histamine levels (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.165).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">Skin and/or specific IgE tests were performed in 46 (69.7%) of 66 patients. Skin testing together with specific IgE testing allowed identification of the causative agent in 39 (84.8%) of 46 patients. Skin tests were positive in 33 patients and IgE-positive in another six patients, in whom no IgE-positive skin tests were performed (two for amoxicillin/clavulanic acid, four for latex), and therefore the reaction could be considered IgE-mediated anaphylaxis. Negative skin tests and/or specific IgE allowed us to classify the reaction as non-IgE-mediated in seven (15.2%) of 46 patients (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><p id="par0090" class="elsevierStylePara elsevierViewall">Late diagnostic tests (skin and specific IgE) could not be performed in three patients because they died, and in 17 patients due to severe uncontrolled disease or because they refused the tests.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Serum tryptase at 2<span class="elsevierStyleHsp" style=""></span>h was higher in IgE-mediated reactions than in non-IgE-mediated reactions (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.020). This association was observed in both univariate and multivariate analyses adjusted for age and sex [odds ratio (OR) 10.42, 95% confidence interval (CI) 4.04–103.95].</p><p id="par0100" class="elsevierStylePara elsevierViewall">Plasma histamine levels, measured in 44 patients, were higher in IgE-mediated reactions, but without statistical significance (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.414).</p><p id="par0105" class="elsevierStylePara elsevierViewall">Although we found no relationship between age and reaction severity (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.957), poorer physical fitness (ASA) was associated with greater severity (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.02).</p><p id="par0110" class="elsevierStylePara elsevierViewall">We studied 19 of the 24 patients with a history of drug allergy. Reactions were IgE-mediated in 18 (94.7%) and non-IgE-mediated in one (5.2%), but we found no difference between the two groups (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.224). Thirteen of the 16 patients with a history of atopy were also studied; reactions were IgE-mediated in 10 (81.2%) patients and non-IgE-mediated in three (18.8%), with no significant differences (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.392). We also found no correlations with reaction type when assessing patients with a history of drug and/or food allergy or atopy (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.028). However, serum tryptase levels at two hours were significantly higher in these patients (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.028). In the case of histamine extracted in the first 15<span class="elsevierStyleHsp" style=""></span>min, we found no difference between the two groups (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.110).</p><p id="par0115" class="elsevierStylePara elsevierViewall">In IgE-mediated anaphylaxis, serum tryptase levels (2<span class="elsevierStyleHsp" style=""></span>h) were 6.9 times higher compared to baseline tryptase (24<span class="elsevierStyleHsp" style=""></span>h) and only 2.2 times higher in non-IgE-mediated anaphylaxis. These differences were not significant (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.122).</p><p id="par0120" class="elsevierStylePara elsevierViewall">Skin testing, together with specific IgE testing, identified the causative agent in 39 (84.8%) of 46 patients. The causative agents identified were antibiotics in 14 (35.8%) cases, NSAIDs in nine (23.07%), NMB in six (15.38%), latex in six (15.38%), and other in four (10.25%) (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). In skin tests, cross-reactions between NMB were observed in three patients (50%). Among the antibiotics, cross-reactions between β-lactams were observed in three patients (21.4%), and among NSAIDs, in one patient (11.1%).</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discussion</span><p id="par0125" class="elsevierStylePara elsevierViewall">Anaphylaxis reactions are of great concern to anaesthesiologists as they are rare and unexpected events that can have serious sequelae and even result in death. Published incidence rates are variable and range from 1 in 1480 to 1 in 13,000 anaesthetic procedures<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2,4,6</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10–13</span></a> with a mortality rate of 3% and 9%<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3,5,6</span></a>. English<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and French<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,10</span></a> studies consider it likely that the published incidence of allergic reactions is greatly underestimated. Between 55% and 60% of these reactions are severe (class III–V)<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,10,14</span></a>. In our study the incidence of severe reactions was 1 in 4327 anaesthetic procedures, higher than that published in other studies, but similar to the incidence reported by Saager et al.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> (1 in 4583 procedures).</p><p id="par0130" class="elsevierStylePara elsevierViewall">Most studies found a higher incidence of anaphylaxis in women and in a mean age of 45–55 years<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,7,11,16</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>. However, Garvey et al.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> found a higher incidence of severe reactions in men. The incidence also appears to be higher in patients with a history of atopy and drug allergy<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,12,16</span></a>. In our study we observed a slightly higher frequency of severe anaphylaxis in men (59%), with a slightly higher mean age (61 years) than in other studies. In terms of risk factors, 36.4% of our patients had a history of drug allergy and 24.2% were atopic. However, as we did not study the entire surgical population, we could not determine whether this subgroup of patients has an increased risk of anaphylaxis. In a previous study conducted in our hospital, the prevalence of atopy in a surgical population was similar (32%), but the prevalence of drug allergy was much lower (13%) than in the present study<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>. Several studies<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,12,19,20</span></a> have shown that atopy and drug allergy do not influence the type of reaction and that, despite the higher frequency in patients with IgE-mediated reactions, they cannot be considered predictors of risk. Our study also found no significant correlation between patients with a history of atopy and drug allergy and the type of reaction they had.</p><p id="par0135" class="elsevierStylePara elsevierViewall">In our cohort we found no correlation between patient age and reaction severity. However, the poorer the physical condition of the patient (ASA), the greater the severity of the reaction.</p><p id="par0140" class="elsevierStylePara elsevierViewall">In published series, 92%–97% of clinical manifestations of anaphylaxis appeared in the first minutes after parenteral administration of drugs or mucosal absorption of<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,7,11,12</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16,19</span></a> and the period of highest risk was induction of anaesthesia (70%–80%)<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3,4,7</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,12,19</span></a>. In our study, most anaphylaxis reactions (89.4%) were immediate and the time of highest risk was at induction of anaesthesia (59%), followed by the PACU stay (21%). These differences with respect to French, Australian and English studies<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3,4,7</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,19</span></a> could be because they only considered intraoperative reactions, thus showing a higher percentage of anaphylaxis during induction. Our results are similar to those of two other Spanish studies<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11,12</span></a>, which found that 57% and 64% of reactions occurred during induction and 23% in the PACU.</p><p id="par0145" class="elsevierStylePara elsevierViewall">In our study, the predominant signs of severe anaphylaxis were cardiovascular (86.4%), respiratory (72.7%), and mucocutaneous (56.1%). Cardiovascular and especially respiratory symptoms were more frequent in IgE-mediated anaphylaxis. Mertes et al.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,10</span></a> reported similar findings.</p><p id="par0150" class="elsevierStylePara elsevierViewall">In France, immunological (IgE-mediated) origin has been confirmed in 72.2% of anaphylaxis reactions<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>. Krishna et al.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> in the UK (64%), Lobera et al.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> and Berroa et al.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> in Spain (52%–56%), and Gurrieri et al.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> in the USA (47.4%). The percentage (84.8%) was higher in our study, perhaps because we only included severe reactions (class III–V). Garvey et al.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> also found that 75% of severe reactions were IgE-mediated.</p><p id="par0155" class="elsevierStylePara elsevierViewall">In most published studies<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,7,8,12</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21–24</span></a>, NMB were the drugs most frequently implicated in anaphylaxis, followed by latex and antibiotics. However, in our study the main causative agents identified were antibiotics (35.8%), especially those of the β-lactam group, followed by NSAIDs (23.1%), NMB (15.4%), and latex (15.4%). Other authors<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,7,9,11</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> also found antibiotics to be the leading cause of allergic reactions. In Spain, Berroa et al.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> reported that NSAIDs, mainly pyrazolones, were involved in 20% of cases, which confirms our results. In other countries, the incidence of reactions to NSAIDs is probably lower than in Spain as pyrazolone-derived drugs are not commercially available.</p><p id="par0160" class="elsevierStylePara elsevierViewall">Mertes et al.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> found that in 58% of cases a NMB was the substance responsible. Other authors<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,21,25,26</span></a> report rocuronium to be the NMB most frequently associated with IgE-mediated reactions. In our series, rocuronium (50%) was the NMB most frequently implicated in IgE-mediated anaphylaxis. However, no conclusions can be drawn from these results, as they are from a single hospital, where this NMB is the most frequently used. In the skin tests, we found cross-reactivity between NMB in 50% of the patients studied. These findings, similar to those of Lobera et al.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> (58%) and Mertes et al.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> (63%), confirm the obligation to study all patients with positive skin tests for any NMB because of the high risk of cross-reactivity between all NMB<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,11,21</span></a>.</p><p id="par0165" class="elsevierStylePara elsevierViewall">In our cohort, latex was identified as the causative agent in six patients. Of these, four had a known history of asthma, three of fruit allergy, and four of drug allergy. Further questioning revealed that three (50%) had a history suggestive of latex sensitivity. Mertes et al.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> found that the prevalence of latex sensitivity was higher among atopic or fruit or other food allergic patients and that 34% of those re-interrogated after the reaction had a history suggestive of latex allergy.</p><p id="par0170" class="elsevierStylePara elsevierViewall">Our results confirm those published in other studies<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3,7,25–27</span></a>, in which serum tryptase levels measured at 2<span class="elsevierStyleHsp" style=""></span>h and 6<span class="elsevierStyleHsp" style=""></span>h from the onset of the reaction were significantly higher in the most severe reactions and proved a more sensitive parameter than plasma histamine levels<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13,22</span></a>. We were also able to confirm, as in other studies<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,12,22,28</span></a> that serum tryptase levels at 2<span class="elsevierStyleHsp" style=""></span>h are higher in IgE-mediated anaphylaxis. Although serum tryptase level testing has a low sensitivity for the diagnosis of anaphylaxis, it has a positive predictive value of 92.6%<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>. Krishna et al.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> found a positive predictive value >80% for an absolute tryptase value >15.7<span class="elsevierStyleHsp" style=""></span>μg<span class="elsevierStyleHsp" style=""></span>L<span class="elsevierStyleSup">−1</span> and concluded that a higher value is highly predictive of IgE-mediated anaphylaxis. Berroa et al.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> support these results by stating that a tryptase increase 2-fold above baseline allows differentiation of IgE-mediated reactions and Mertes et al.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>, found that absolute values >25<span class="elsevierStyleHsp" style=""></span>μg<span class="elsevierStyleHsp" style=""></span>L<span class="elsevierStyleSup">−1</span> suggest an IgE-mediated anaphylaxis.</p><p id="par0175" class="elsevierStylePara elsevierViewall">The main limitations of our study were the small sample size and the fact that there have been changes in anaesthesia practice over the 20 years of follow-up, mainly in the use of NMB, which may have partially biased the results. However, it is important to bear in mind that since all variables were collected in the computer system in a standardised way from the very onset of the anaphylaxis and all diagnostic tests followed a pre-established protocol, the quality of the data is superior to that of large retrospective studies<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4,7,19</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>. Another limitation is that we did not record mild to moderate reactions (class I–II) and therefore do not know the total incidence of anaphylaxis and the percentage represented by severe anaphylaxis. In most published prospective studies<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,11,12,15</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a>, the sample size is small, ranging from 20 to 100 patients, and all degrees of severity are included, and therefore there are very few cases of severe reactions, unlike in our series, where all cases were severe.</p><p id="par0180" class="elsevierStylePara elsevierViewall">In conclusion, the incidence of severe perioperative anaphylaxis in our hospital was higher than in most other studies. Most were immediate reactions and the period of highest risk was during anaesthetic induction and PACU stay. All patients required treatment, with vasoactive drugs being the most commonly used. Cardiovascular and respiratory symptoms were the most frequent. Despite intensive treatment, mortality was high. Serum tryptase levels proved to be a useful biomarker and correlate well with the severity and type of anaphylaxis. Measurement of plasma histamine concentrations was not useful. Skin and specific IgE tests determined that 84.8% of the reactions studied were of immunological origin. The most frequent causative agents involved were antibiotics, NSAIDs, NMB, and latex.</p><p id="par0185" class="elsevierStylePara elsevierViewall">We recommend that, when anaphylaxis is suspected, the proposed diagnostic protocol and early treatment should be activated immediately. Dissemination of the protocols is necessary to improve diagnosis and survival in severe anaphylaxis reactions.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Authors’ contribution</span><p id="par0190" class="elsevierStylePara elsevierViewall">Fernando Escolano: Study conception and design, data acquisition. Data analysis and interpretation. Drafting of the article and final approval of the article to be presented.</p><p id="par0195" class="elsevierStylePara elsevierViewall">José Yelamos: Conception and design of the study. Coordination of laboratory tests. Critical review of the article. Approval of the final version.</p><p id="par0200" class="elsevierStylePara elsevierViewall">Beatriz Fort and Luis Moltó. Data acquisition. Content review and approval of the final version.</p><p id="par0205" class="elsevierStylePara elsevierViewall">Merce Espona: Preparation of extracts for skin tests. Review of the content and approval of the final version.</p><p id="par0210" class="elsevierStylePara elsevierViewall">Ana Giménez-Arnau: Study conception and design. Performance of the skin tests. Critical review of the article. Approval of the final version.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Funding</span><p id="par0215" class="elsevierStylePara elsevierViewall">No funding of any type was received for this article.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflict of interests</span><p id="par0220" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres1849500" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1608605" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1849499" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1608606" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Statistical analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0020" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0025" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0030" "titulo" => "Authors’ contribution" ] 9 => array:2 [ "identificador" => "sec0035" "titulo" => "Funding" ] 10 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflict of interests" ] 11 => array:2 [ "identificador" => "xack651997" "titulo" => "Acknowledgements" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2021-06-11" "fechaAceptado" => "2021-09-07" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1608605" "palabras" => array:5 [ 0 => "Anaphylaxis" 1 => "Perioperative" 2 => "Tryptase" 3 => "Histamine" 4 => "Skin test" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1608606" "palabras" => array:5 [ 0 => "Anafilaxia" 1 => "Perioperatorio" 2 => "Triptasa" 3 => "Histamina" 4 => "Pruebas cutáneas" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">To assess the incidence of severe perioperative anaphylaxis, the mechanisms involved, the value of laboratory/skin tests, and the most effective treatments.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">A historical cohort study conducted in a tertiary public hospital in Spain. Patients that had undergone anaesthesia during the 20-year period were included. In these patients, 66 cases of severe anaphylaxis were found. In patients with suspicion of severe anaphylaxis, levels of blood histamine at less than 15<span class="elsevierStyleHsp" style=""></span>min and serum tryptase at 2, 6, and 24<span class="elsevierStyleHsp" style=""></span>h following the reaction were determined. Skin and specific IgE tests were performed between 4 and 8 weeks later.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Over the 20-year period, 288 594 anaesthetic procedures were performed. We observed cases of 66 severe anaphylaxis reaction (59% men; age, 60.8<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>17.3 years. Symptoms observed were cardiovascular (86%), respiratory (73%), and mucocutaneous (56%). Elevated serum tryptase levels were associated with degree of severity at 2 (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.0001) and 6<span class="elsevierStyleHsp" style=""></span>h (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.026) and were highest in IgE-mediated reactions (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.020). All patients required treatment, and 3 events were fatal.</p><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">In 84.8% of patients, skin and/or specific IgE tests were positive for antibiotics (35.8%), non-steroidal anti-inflammatory drugs (23.1%), neuromuscular blocking agents (15.4%) and latex (15.4%).</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">The incidence of severe anaphylaxis in our hospital was 1 in 4.373 anaesthetic procedures, with a death rate of 4.5%. All cases required treatment. Serum tryptase was a good predictor of reaction severity. The most frequent causative agents were antibiotics, non-steroidal anti-inflammatory drugs, neuromuscular blocking agents and latex.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Determinar la incidencia de reacciones perioperatorias graves, los mecanismos implicados, los tratamientos realizados y la utilidad del protocolo diagnóstico propuesto.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Estudio de cohorte histórico en un hospital público terciario en España. Se incluyeron pacientes que recibieron anestesia durante 20 años. En pacientes con sospecha de anafilaxia grave, se determinaron los niveles de histamina en sangre en menos de 15<span class="elsevierStyleHsp" style=""></span>minutos y triptasa sérica a las 2, 6 y 24<span class="elsevierStyleHsp" style=""></span>horas después de la reacción. Se realizaron pruebas cutáneas e IgE específica a las 4-8 semanas.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">Durante el período de 20 años, se realizaron 288.594 procedimientos anestésicos. Observamos 66 reacciones de anafilaxia grave (59% hombres; edad: 60,8<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>17,3 años). Los síntomas fueron cardiovasculares (86%), respiratorios (73%) y mucocutáneos (56%). Los niveles elevados de triptasa sérica se asociaron con un mayor nivel de gravedad a las 2 (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>,0001) y 6 horas (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.026) y fueron más elevados en las reacciones IgE mediadas (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>,020). Todos los pacientes requirieron tratamiento y la muerte ocurrió en 3 casos. En el 84,8% de los pacientes las pruebas cutáneas y/o IgE específicas fueron positivas a antibióticos (35,8%), antiinflamatorios no esteroideos (23,1%), bloqueantes neuromusculares (15,4%) y látex (15,4%).</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">La incidencia de anafilaxia grave en nuestro hospital fue 1:4.373 procedimientos anestésicos, con una mortalidad del 4,5%. Todos los casos requirieron tratamiento. La triptasa sérica fue un buen predictor de la gravedad de la reacción. Los agentes etiológicos más frecuentes fueron antibióticos, antiinflamatorios no esteroideos, bloqueantes neuromusculares y látex.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0235" class="elsevierStylePara elsevierViewall">The following are Supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia><elsevierMultimedia ident="upi0010"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0050" ] ] ] ] "multimedia" => array:8 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3364 "Ancho" => 2925 "Tamanyo" => 416956 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0155" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Algorithm for diagnosis in anaphylaxis.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 3152 "Ancho" => 2925 "Tamanyo" => 503353 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0160" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Flow chart in patients with severe anaphylaxis. IDR: intradermal reaction; NMBs: neuromuscular blockers; NSAIDs: non-steroidal anti-inflammatory analgesics.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1116 "Ancho" => 1508 "Tamanyo" => 65030 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0165" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Median tryptase levels at 2<span class="elsevierStyleHsp" style=""></span>h as a function of the degree of severity (III–V) of the anaphylaxis.</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Median (quartile 1; quartile 3): severity III: 10.7 (3.9; 19.4); severity IV: 66.2 (36.9; 113); severity V: 200 (105; 285).</p> <p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Kruskal-Wallis test: <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.0001.</p> <p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Post hoc analysis:</p> <p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">* <span class="elsevierStyleItalic">P</span> between severity III and severity IV<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.001.</p> <p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">** <span class="elsevierStyleItalic">P</span> between severity III and severity V<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.007.</p> <p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">*** <span class="elsevierStyleItalic">P</span> between severity IV and severity V<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>1.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0170" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Cardiovascular signs include, in addition to those specified, loss of consciousness (3 cases) and hypertension (2 cases). Respiratory signs also include hypercapnia (2 cases) and laryngospasm (1 case). Digestive signs include nausea/vomiting/diarrhoea (13 cases), dysphagia (1 case) and epigastric pain (2 cases). Other signs include sweating (2 cases), urinary urgency (1 case), blurred vision (1 case), tinnitus (1 case) and agitation (2 cases).</p>" "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Clinical signs \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>66) n (%) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">IgE-mediated anaphylaxis (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>39) n (%) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Non-IgE-mediated anaphylaxis (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>7) n % \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Skin signs</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">37 (56.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23 (59) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (57.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Erythema \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">32 (48.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23 (59) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (42.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Urticaria \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16 (24.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 (25.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (14.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Angioedema \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 (15.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 (20.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Cardiovascular signs</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">57 (86.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">34 (87.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 (71.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hypotension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">50 (75.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">31 (79.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 (71.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Tachycardia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">43 (65.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">28 (71.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (57.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Bradycardia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 (15.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (10.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (28.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Rhythm disturbances \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 (13.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (10.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cardiac arrest \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (6.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (2.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Respiratory signs</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">48 (72.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">36 (92.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 (71.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Bronchospasm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">33 (50.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27 (69.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 (71.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Desaturation<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>90% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20 (30.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 (38.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (28.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Dyspnoea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 (16.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 (25.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (14.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Respiratory arrest \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 (9.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (10.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Digestive signs</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16 (24.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 (20.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (28.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Other signs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 (16.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 (20.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (28.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Tryptase 2<span class="elsevierStyleHsp" style=""></span>h: median (1st quartile; 3rd quartile) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17.8 (8.3; 40.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.5 (2; 12.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Clinical signs during anaphylaxis.</p>" ] ] 4 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0175" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Treatment \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">n (%) \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vasoactive drugs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">54 (81.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Corticosteroids \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">44 (66.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bronchodilators \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22 (33.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Antihistamines \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 (22.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Colloids \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 (21.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CPR<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 (9.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Antiarrhythmics \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (4.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "*" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">CPR: Cardiopulmonary Resuscitation.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Treatment for anaphylaxis (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>66).</p>" ] ] 5 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0180" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Substances identified \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">% \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">N \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Antibiotics (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>14; 35.8%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">β-lactams \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(100) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NSAIDs<a class="elsevierStyleCrossRef" href="#tblfn0010">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Metamizole \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(77.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>9; 23.07%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diclofenac \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(22.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NMB<a class="elsevierStyleCrossRef" href="#tblfn0010">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Rocuronium \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(50) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>6; 15.38%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cisatracurium \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(16.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Atracurium \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(16.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Succinylcholine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(16.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Latex (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>6; 15.38%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Other substances \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Protamine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(50) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>4; 10.25%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lidocaine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(25) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ranitidine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(25) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "*" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">NMB: Neuromuscular Blocker; NSAIDs: Non-steroidal anti-inflammatory drugs.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Substances identified in skin tests and/or specific IgE as responsible for perioperative allergic reactions (IgE-mediated) (total<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>39).</p>" ] ] 6 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.docx" "ficheroTamanyo" => 17215 ] ] 7 => array:5 [ "identificador" => "upi0010" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc2.docx" "ficheroTamanyo" => 13638 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:28 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Anaesthesia, surgery, and life-threatening allergic reactions: epidemiology and clinical features of perioperative anaphylaxis in the 6th National Audit Project (NAP6)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "N.J.N. Harper" 1 => "T.M. Cook" 2 => "T. Garcez" 3 => "L. Farmer" 4 => "K. Floss" 5 => "S. Marinho" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.bja.2018.04.014" "Revista" => array:6 [ "tituloSerie" => "Br J Anaesth." "fecha" => "2018" "volumen" => "121" "paginaInicial" => "159" "paginaFinal" => "171" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29935567" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prospective epidemiological study of perioperative anaphylactoid reactions in Catalonia in 1996 and 1997)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "F. Escolano" 1 => "A. Valero" 2 => "J. Huguet" 3 => "P. Baxarias" 4 => "M. De Molina" 5 => "A. 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"fecha" => "2007" "volumen" => "62" "paginaInicial" => "471" "paginaFinal" => "487" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17441788" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack651997" "titulo" => "Acknowledgements" "texto" => "<p id="par0225" class="elsevierStylePara elsevierViewall">The authors would like to thank Xavier Durán for his support in the statistical analysis (Department of Statistics, Hospital del Mar Medical Research Institute [IMIM], Barcelona).</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/23411929/0000007000000001/v1_202302161340/S2341192923000045/v1_202302161340/en/main.assets" "Apartado" => array:4 [ "identificador" => "34051" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Original articles" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23411929/0000007000000001/v1_202302161340/S2341192923000045/v1_202302161340/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192923000045?idApp=UINPBA00004N" ]
