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Practical guidelines for the response to perioperative anaphylaxis


Perioperative anaphylaxis is a severe adverse event during anesthesia that requires prompt diagnosis and treatment by physicians, including anesthesiologists. Muscle relaxants and antibiotics are the most common drugs that cause perioperative anaphylaxis in Japan, as in many countries. In addition, sugammadex appears to be a primary causative agent. Obtaining previous anesthesia records is necessary in a patient with a history of allergic reactions during anesthesia, whenever possible, to avoid recurrence of anaphylaxis. Although medical staff are likely to notice abnormal vital signs because of complete monitoring during anesthesia, surgical drapes make it difficult to notice the appearance of skin symptoms. Even if there are no skin symptoms, anaphylaxis should be suspected, especially when hypotension resistant to inotropes and vasopressors persists. For improving the diagnostic accuracy of anaphylaxis, it is helpful to collect blood samples to measure histamine/tryptase concentrations immediately after the events and at baseline. The first-line treatment for anaphylaxis is adrenaline. In the perioperative setting, adrenaline should be administered through the intravenous route, which has a faster effect onset and is secured in most cases. Adrenaline can cause serious complications including severe arrhythmias if the appropriate dose is not selected according to the severity of symptoms. The anesthesiologist should identify the causative agent after adverse events. The gold standard for identifying the causative agent is the skin test, but in vitro tests including specific IgE antibody measurements and basophil activation tests are also beneficial. The Working Group of the Japanese Society of Anesthesiologists has developed this practical guide to help appropriate prevention, early diagnosis and treatment, and postoperative diagnosis of anaphylaxis during anesthesia.

Grade of recommendations and levels of evidence Anaphylaxis is a relatively rare condition with few controlled trials, and thus a so-called evidence-based scrutiny is difficult. Therefore, rather than showing evidence levels and indicating the level of recommendation, this practical guideline only describes the results of research available to date. The JSA will continue to investigate anaphylaxis during anesthesia, and the results may lead to an amendment of this practical guideline.

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The creation of this guide was funded by the Japanese Society of Anesthesiologists (JSA). This guide will be published and accessible free of charge online via the JSA’s official web site.

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Correspondence to Tomonori Takazawa.

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This guide is designed to provide anesthesiologists with useful information for the prevention, early diagnosis and treatment, and postoperative diagnosis of anaphylaxis during anesthesia. Many recommendations contained in this guide are based on expert opinion and case reports in the absence of high-quality evidence, because anaphylaxis is a relatively rare condition. This document aims to assist anesthesiologists’ decision making in clinical settings, and these guidelines are not recommended to general physicians.

Practical guidelines for the response to perioperative anaphylaxis were published in Japanese in February 2021. We share these guidelines in English with healthcare professionals and the general public around the world to improve medical practice and patient outcomes.


This practical guideline is not intended for all cases of anaphylaxis, but only for those that occur during anesthesia. The major differences between anesthetized patients and general patients are the differences in the causes of anaphylaxis and the availability of venous routes and airways at the onset of anaphylaxis. Additionally, since patients tend to be fully monitored, it is easy to notice abnormal vital signs, but it can be difficult to notice the emergence of skin symptoms in areas where the skin is covered by surgical drapes.

Target audience

The target audience of this guide is anesthesiologists who conduct anesthetic management in operating rooms. This guide is not recommended to general physicians, because anaphylaxis during anesthesia is a special condition in which patients are anesthetized, and most cases are already maintained with an airway, intubated, and maintained under continuous monitoring of vital signs. Furthermore, anesthesiologists are specialists in resuscitation and are familiar with the use of adrenaline and defibrillators that are present in the operating rooms.

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Takazawa, T., Yamaura, K., Hara, T. et al. Practical guidelines for the response to perioperative anaphylaxis. J Anesth 35, 778–793 (2021).

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  • Anaphylaxis
  • Shock
  • Anesthesia
  • Guideline