Anafilaksis.pdf

8/12/2019 Anafilaksis.pdf

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dr. T.Mamfaluti, Mkes,. Sp. PD

Sub. Alergi ImunologiBagian Ilmu Penyakit Dalam FK Unsyiah/RSUD Dr Zainoel Abidin

Banda Aceh


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Reaksi hipersensitivitas tipe 1SistemikMengancam hidup

Timbul beberapa menitGejala : Saluran nafas Kardiovaskuler Kulit Saluran cerna


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Lawan kata : PROPHYLAXIS

ANAPHYLACTOID IgE

Sifat alergen AtopikJalur pemberian obatGenetik

PREDISPOSISI :


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Indonesia ?USA : 150 oleh makanan

1 tahun 400 800 oleh antibiotik 250 1000 oleh media kontras


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Protein : Hormon, enzym, Pollen,Non Pollen, Makanan,

AntiserumPolisakarida : Bahan pengawet vaksin

(thyomerosal)Obat : Antibiotik, Anestesi lokal


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MEDICATIONSNonsteroidal antiinflammatory drugs, aspirin,

antibiotics, opioid analgesics, insulin, protamine,general anesthetics, streptokinase, bloodproducts, progesterone, radiocontrast media,biologic agents, immunotherapy

FOODSPeanuts, tree nuts, fish, shellfish, milk, eggs,

bisulfitesHYMENOPTERA VENOMHoneybees, fire ants etc

MISCELLANEOUSLatex, exercise, gelatin, menstruation, seminal fluid,

dialysis membranes

Adapted from Rusznak and Peebles.


7/27A. Miyamoto: Clinical allergology 2nd edition, Nankoudou, 1998, pp94 (modified)

Type(Alternative names)

Antibody(Ab)

Antigen(Ag) Related cells Mediators Representative diseases

Type

(Immediate type,

Anaphylactic type)

IgE Foreign antigen (Mite, pollen,

Fungi, etc.)

Mast cell Basophil

Eosinophil

Histamine

Leukotriene

PAF, etc.

Asthma Allergic rhinitis Urticaria Atopic dermatitis

Type(Cytotoxic type,

IgG IgM

Fereign antigen (drugs)

Self antigen

Killer cell Complement Drug allergy Autoimmune hemolytic anemia

Type

(Immune complex type,

Arthus type)

IgG

IgM

Foreign antigen

(Bacteria, drugs)

Self antigen

Mast cellBasophilEosinophil

Complement Ag-Ab complex

Systemic lupus erythematosus

Rheumatoid arthritis

Glomerular nephritis

Type

(Delayed type, Cell-mediated immune type, Tuberculin type)

Foreign antigen (Bacteria, fungi)

Self antigen

T cell Cytokine Contact dermatitis Tuberculin reaction

Coombs & Gell classification of hypersensitivity

Ab-dependent type)


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Type Type ofimmunrespon

Pathophysiology

Clinicalsymptoms

Chrononology ofthe reaction

IVa Th1 (IFNy) Monocytic

inflamation

Eczeme 5-21 hari

IVb TH2 (IL-5 danIL-4)

Eosinophilicinflamation

Maculo-papularexanthema,bullous

exanthema

2- 6 minggu

IVc Cytotoxic Tcells

Keratinocytedeathmediated byCD4 or CD8

Maculo-papularexanthema,bullousexanthema

2 hari setelahpengobatan fixeddrug eruption, 7-21 hari setelahpengobatan SJSatau TEN

IVd T cells (IL-8 ) Neutrophilicinflammation

Acutegeneralizedexanthemato

us pustulosis

Kurang dari 2 hari


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ALERGEN

Diproses di monocytic lineage cell

Stimulasi T cell (Th 2)

SitokinIL 4

Stimulasi sel plasma

IgE spesik

Mast cellbasofil

terikat

AlergenReexposure

MediatorBioaktif

Histamin, dll

Respons Biologial. Kulit Sal. Nafas - Vaskuler


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Activation ofEosinophil

Promotion of Eosinophildifferentiation and proliferation

Histamine releaseand PAF, LTC4, LTD4 production from mast cell

LTC4, PAF productionand EPO, ECP, MBPrelease from grunulocyte

Immediate phasereaction

Late phasereaction

IgE production

Promotion of B celldifferentiation and proliferation

Eosinophil

Thymus

Differentiation

IL-5

IL-4

IL-5

IL-4Promotion ofdifferentiation

IL-5

Eosinophil

LT

Immediate and Late phase reaction of type I hypersensitivity

Mast cell

Th0

Th2

Th1

B cellSeveral min 10 min

6-12 hoursHematopoietic

stem cell

Bone marrow

Antigen

Differentiation


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Leukocyte responses Adherence Chemotaxis IgE production

Mast Cell proliferation Eosinofil activation

Fibroblast responses Proliferation Vacuolation Globopentaosylceramide

production Collagen production

Substrate responses Activation of matrix

metalloproteases

Activation of coagulationcascade

Microvascular responses Augmented venular permeability Leukocyte adherence Constriction dilatation

Lipid mediators LTB 4 LTC 4 PAF

PGD 2

Secretory granulepreformed mediators Histamine Proteoglycans

Tryptase and chymase Carboxypeptidase A

Cytokines IL-3 IL-4 IL-5 IL-6 GM-CSF IL-13 IL-1INF- TNF-

Ac t iv i t ed Mas t Ce l l


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Lipid mediators (PGD2, PAF, Leukotriene, dll)Cytokine (IL-3, IL-4, IL-5, IL-6, TNF, INF, dll)Secretory granule preformed mediators (Histamin,typtase, dll)

Respons BiologiLekosit (aderen, kemotaksis, aktivasi eosinofil)

Aktivasi sistim koagulasi ( DIC) Mikrovaskuler (permeabilitas , dilatasi)Cysteinil leukotrienes konstruksi bronhusHistamin urtikaria, angioedema, hipotensiSistim kinin , PGD2 HIPOTENSI


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ONSET : - ~ INDIVIDU- Detik Menit

Riwayat Allergen Parenteral, Peroral20% : 6 12 jam Rekurens, bifasik

Rochester Epidemiologic study (1983 1987) :150 kasus Kulit 100%, Sal. Nafas 69%,K. Vaskuler 41%, Sal. Cerna 24%


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Edema Laring (mengganjal, serak, stridor insp.)Bronchospasme (tertekan dada, wheezing)BatukRhinorrhea


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Tanda khas DD Jarang sebagai gejala pertamaUrtikaria (lokal, general : < 48 jam)Flushing

AngioedemaRasa terbakar, pedih, tidak terasa


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HipotensiSyokGejala pertama

AritmiaGangguan konduksiIskemi miokard

Sal. Cerna

Mual, Muntah, Kolik, Diare


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Patients (N=133)Symptom or Sign N %Cutaneous

Urticaria AngioedemaPruritusFlushing

Conjunctivitis or chemosisRespiratoryDyspneaThroat tightnesswheezingRhinitisLaryngeal edemaHoarseness

73747348

30

6737342299

56565536

23

4328261777

Reproduced with permission from Yocum et al.

Source : Semin Respir Crit Care Mes @ 2004 Thieme Medical Publisher


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Patients (N=133)Symptom or Sign N %Oral and gastrointestinal

Intraoral angioedema

EmesisNausea

Abdominal crampsDysphagiaOral prurius

DiarrheaCardiovascularTachycardiaPresyncopeHypotensionSyncopeShockChest painBradycardiaOrthostatis

20

12121175

1

36201547422

15

99854

1

27151135322

Reproduced with permission from Yocum et al.Source : Semin Respir Crit Care Mes @ 2004 Thieme Medical Publisher


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Secara klinis !!Riwayat (Alergen, Onset)Pemeriksaan Fisik : Gambaran Klinik

Lab

IgE TestTryptase Test

DD

Penyebab lain dari Syok, Hipotensi dan

Respiratory Distress


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Evaluasi Tanda VitalMedikamentosa

1. EpinephrineVasokontriksi, bronchodilator, permeabilitasvaskuler , sintesa mediator Sedini mungkinTidak dapat diganti yang lain !SC/1m iv

2. Oksigen3. Infus replacement cairan

4. Vasopressor (Dopamine) ditambahkan ?


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Lainnya

5. Nebulizer tambahan untuk Bronchospasme 6. Intubasi/Trakheotomi lihat hipoksia progresif ?

7. Antihistamin kel. Kulit, sal. Cerna 8. Aminofilin tambahan untuk Bronchospasme 9. Kartikosteroid >< Rekuren/prolong Reaction

10. Terapi Aritmia11. CVP ?


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Source : Curr Opin Allergy Clin Immunol @ 2005 Lippincott Williams Wilkins

1. Epinephrine Infusion1 mg in 100 ml (1:100 000, 10 g/ml) intravenously by infusion pump

commence at 30 100 ml/h (5-17 g/min)according to reaction severity titrate up or down according to response and side effects, aiming for

lowest effective infusion rate tachycardia, tremor and pallor in the setting of a normal or raised blood

pressure are signs of epinephrine toxicity; consider a reduction in infusionrate

stop infusion 30 min after resolution of all symptomps and signs continue observation for at least 2 h after ceasing infussion (longer for

severe or complicated reactions); discharge only if remains symptom-free2. Normal saline rapid infusion

1000 ml (pressurized) infused over 1-3 min and repeat as necessary give if hypotension is severe or does not respond promptly to epinephrine

Reprinted with permission from the BMU.

Table 2.


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Source : Curr Opin Allergy Clin Immunol @ 2005 Lippincott Williams Wilkins

1. Lie flat, elevate legs/Trendelenburg position, high-flow oxygen, supportairway and assist ventilation as required

2. Administer IM epinephrine 0.01 mg/kg (max 0.5 mg) into the anterolateral

thigh and proceed to obtain wide-bore intravenous access.(if IV access is present and patient is in an appropriate environment, may omitIM epinephrine and proceed directly to intravenous infusion of epinephrine)

3. Once IV access is available, commence rapid volume resuscitation withNormal Saline or Hartmanns Solution (20 ml/kg start under pressure,repeated as necessary).

4. If remains hypotensive despite above steps, consider in the followingsequence :

a) Intravenous infusion of epinephrine using an infusion pump (Table 2)b) Intravenous bolus of atropine, if there is significant bradycardiac) Intravenous bolus of vasoconstrictor (e.g. Mataraminol, Methoxamine,

Vasopressin)d)Further investigation/monitoring (central/pulmonary artery cannulation,

echocardiography) to monitor intravascular volume and cardiac functione) Intravenous glucagon, milrinone/amrinone and/or mechanical support (intraaortic ballon pump) if remain hypotensive with a suspicion of cardiac failurerather than volume depletion/vasodilation. Cardiac support may be morelikely to be required if there is coexisting beta-blockade or underlyingcardiac disease.

Table 3. Suggested Management of Anaphylactic Shock


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Anamnesa :

Skin Test :

Penting ! Riwayat alergi/anafilaksis

(walau tidak menjamin !!) Cari alergennya Awas reaksi silang Harus dilakukan pada zat

yang bisa alergen Ideal :

Tidak menjamin

Prick Skin Test/Scratch Test

Tersedia KitSiaga


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Monitor post exposureDesensitisasi ?

Edukasi untuk yang resiko !Epinephrine Autoinjector Kit


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Berat reaksiLamanya onsetEdema LaringSyokWaktu antara onset Klinikdan dimulai terapi


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