Lessons Learned From Fatal and Near-Fatal Perioperative IgE-Mediated Anaphylaxis.

Authors

Pascale Dewachter, Claudie Mouton-Faivre, Agathe Vianey-Liaud, Eric Vicaut, Sadek Beloucif

Published in

The journal of allergy and clinical immunology. In practice. Aug 14, 2026. Epub Aug 14, 2026.

Abstract

Perioperative anaphylaxis (POA), an acute circulatory failure usually IgE-mediated, remains a significant cause of anesthesia-related deaths. Because early recognition of this life-threatening condition is critical, we previously investigated the association of clinical characteristics with IgE-mediated allergy and showed that early cutaneous vasoconstriction was pathognomonic of IgE-mediated anaphylaxis.
To evaluate whether early cutaneous vasoconstriction phenotype is associated with an increased risk of fatal/near-fatal POA and analyze the mechanisms leading to poor outcomes.
This is a prespecified analysis of a retrospective observational cohort study conducted at 2 academic medical centers. Included in the study were adults diagnosed with IgE-mediated anaphylaxis (grades III and IV according to the modified Ring and Messmer scale) in the main analysis and those with a fatal or near-fatal outcome. IgE-mediated anaphylaxis successfully treated with mechanical circulatory support was defined as near-fatal.
Of 72 included patients with IgE-mediated anaphylaxis (grade III: 65 [90.3%] and grade IV: 7 [9.7%]), 45 (62.5%) and 27 (37.5%) were, respectively, categorized in the miscellaneous (early or late cutaneous vasodilation or lack of cutaneous signs) and early cutaneous vasoconstriction groups. Six fatal or near-fatal cases (grade III: 4 and grade IV: 2) were exclusively reported in the early cutaneous vasoconstriction group. Early cutaneous vasoconstriction phenotype was associated with fatal/near-fatal outcomes. Fatal/near-fatal outcomes occurred in 22.2% of patients with cutaneous vasoconstriction (n = 6 of 27) while in none of those from the miscellaneous group (n = 0 of 45) (absolute risk difference: 22.2% [95% confidence interval: 8.2-40.8]). Fatal and near-fatal cases accounted for 18.5% (n = 5 of 27) and 3.7% (n = 1 of 27) of cases, respectively. Early cutaneous vasoconstriction was always associated with bradycardia (median [interquartile range]: 46 [38-57] beats/min) in the 6 fatal/near-fatal cases. A symptomatic treatment, disregarding the pathophysiological mechanisms of POA, might have contributed to poor outcomes.
POA exhibiting early cutaneous vasoconstriction was associated with an increased risk of fatal/near-fatal outcomes. Early cutaneous vasoconstriction and bradycardia likely reflect greater initial severity, owing to profound hypovolemia. This highlights the importance of recognizing this lesser-known phenotype. Further research is warranted.

PMID:
42599270
Bibliographic data and abstract were imported from PubMed on 14 Aug 2026.

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