Proposed mechanisms of perioperative anaphylaxis

Agents	Immunologic reactions		Nonimmunologic
	IgE mediated	Non-IgE mediated	Testing not available
	Skin testing and sometimes in vitro testing is possibly helpful^*	Testing not available	Testing not available
Neuromuscular-blocking agents	+	–	+
Antibiotics	+ (eg, beta-lactams)	Possible	+ (eg, fluoroquinolones, vancomycin)
Chlorhexidine	+	Possible	–
Blue dyes	+	–	Possible
Hypnotic induction agents:
Barbiturates	+	+	+
Nonbarbiturates	Possible	+	+
Opioids	Possible	–	+
Colloids and plasma expanders	+	+	+
Sugammadex	+	–	Possible
Latex	+	–	–

There are at least three distinct mechanisms for perioperative anaphylaxis: IgE mediated, non-IgE mediated, and nonimmunologic (direct mast cell activation). Allergy skin testing is useful in the identification of IgE-mediated reactions only.

IgE: immunoglobulin E.

* Skin testing is only validated for penicillins and other beta-lactam antibiotics. Despite this, it can be helpful for evaluating immediate allergic reactions to drugs in other classes.

Graphic 60805 Version 18.0

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Proposed mechanisms of perioperative anaphylaxis