Anaesthesia 2024 doi:10.1111/anae.

16229

Original Article

Peri-operative cardiac arrest due to suspected anaphylaxis

as reported to the 7th National Audit Project of the Royal
College of Anaesthetists
T. M. Cook,1,2 A. D. Kane,3,4 R. A. Armstrong,4,5 E. Kursumovic1,4 and J. Soar6

1 Consultant, Department of Anaesthesia and Intensive Care Medicine, Royal United Hospitals Bath NHS Foundation
Trust, Bath, UK
2 Honorary Professor School of Medicine, University of Bristol, Bristol, UK
3 Consultant, Department of Anaesthesia, James Cook University Hospital, Middlesbrough, UK
4 Research Fellow, Royal College of Anaesthetists, London, UK
5 Specialty Registrar, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
6 Consultant, Department of Anaesthesia and Intensive Care Medicine, Southmead Hospital, Bristol, UK

Summary
The 7th National Audit Project (NAP7) of the Royal College of Anaesthetists studied peri-operative cardiac
arrest. Among 59 cases reported as possible anaphylaxis, 33 (56%) were judged to be so by the review panel
with high or moderate confidence. Causes in excluded cases included: isolated severe hypotension;
bronchospasm; and oesophageal intubation. Severe bronchospasm leading to cardiac arrest was uncommon,
but notably in one case led to a reported flat capnograph. In the baseline survey, anaesthetists estimated
anaphylaxis as the cause of 10% of cases of peri-operative cardiac arrests and to be among the four most
common causes. In a year-long registry of peri-operative cardiac arrest, suspected anaphylaxis was the seventh
most common cause accounting for 4% of reports. Initial management was most often with low-dose
intravenous adrenaline, and this was without complications. Both the NAP7 baseline survey and case registry
provided evidence of reluctance to starting chest compressions when systolic blood pressure had fallen to
below 50 mmHg and occasionally even when it was unrecordable. All 33 patients were resuscitated
successfully but one patient later died. The one death occurred in a relatively young patient in whom
chest compressions were delayed. Overall, peri-operative anaphylaxis leading to cardiac arrest occurred
with a similar frequency and patterns of presentation, location, initial rhythm and suspected triggers in
NAP7 as in the 6th National Audit Project (NAP6). Outcomes in NAP7 were generally better than for
equivalent cases in NAP6.

.................................................................................................................................................................
Correspondence to: T. M. Cook
Email: timcook007@gmail.com
Accepted: 15 December 2023
Keywords: anaesthesia; anaphylaxis; bronchospasm; cardiac arrest; death
Twitter/X: @doctimcook; @adk300; @drrichstrong; @emirakur; @jas_soar

Introduction bronchospasm (grade 3) or leading to cardiac arrest (grade

Life-threatening anaphylaxis during anaesthesia can 4) or death (grade 5) [1]. The 6th National Audit Project of
be serious, presenting with severe hypotension or the Royal College of Anaesthetists (NAP6) [2–4] studied

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This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use,
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Anaesthesia 2024 Cook et al. | Cardiac arrest due to suspected anaphylaxis in NAP7
life-threatening (grades 3–5) peri-operative anaphylaxis and
estimated the incidence as 1 in 11,752 anaesthetics, noting
that delayed or incomplete reporting meant the incidence
might be up to 70% higher, e.g. approximately 1 in 7000
anaesthetics [3]. Since NAP6 was published, international
consensus guidelines have emerged on managing peri-
operative anaphylaxis [5, 6]. The Resuscitation Council UK
(RCUK) has published guidelines on the general
management of anaphylaxis [7]. In contrast, the Association
of Anaesthetists has withdrawn its peri-operative
anaphylaxis guideline [8], although the topic is included in
the Quick Reference Handbook [9].
Five years after NAP6, the 7th National Audit Project
(NAP7) studied peri-operative cardiac arrest in the UK, and
within these cases, some are inevitably caused by
anaphylaxis [10]. Grade 3–5 peri-operative anaphylaxis
events were studied by NAP6 and required confirmation of
allergy by an allergy or immunology clinic before cases
were reported [1]. It is plausible that not all cases of
anaphylaxis occurring in the NAP6 window were referred for
specialist follow-up or diagnosed correctly and therefore
may not have been included. In contrast, NAP7 includes
only cases of cardiac arrest (grade 4–5) and there was no
requirement for confirmation of anaphylaxis by further
testing [11]. Thus, it is likely that NAP6 may have
underestimated cases of grade 3–5 anaphylaxis and NAP7
may have overestimated the number of cases of grade 4–5
anaphylaxis.
Whether adrenaline should be administered
intramuscularly or intravenously for peri-operative
anaphylaxis is debatable. While adrenaline is accepted as a
key drug for the treatment of anaphylaxis, concerns have
been expressed about the risk of dose-related
complications when it is used intravenously, especially in
older patients, in unmonitored settings and by those who
would not usually use an intravenous vasopressor [12]. Early
use of intravenous adrenaline is recommended in the NAP6
report [13], a consensus statement from the International
Suspected Peri-operative Allergic Reaction Group [5] and
the most recent version of the Quick Reference Handbook
[9]. Conversely, the RCUK 2021 guidelines [7], which are not
specifically for peri-operative care, emphasise
intramuscular use stating that ``Intramuscular adrenaline is
the first-line treatment for anaphylaxis even if intravenous
access is available´´. The guidance goes on to describe
intravenous administration of adrenaline by those who are
expert in its use. In NAP6, there were no reported
complications attributed to excessive intravenous dosing or
drug error with adrenaline. In the absence of cardiac arrest,
intravenous dosing of adrenaline in adults is recommended
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in the range of 10–50 lg, increasing in resistant cases to
100–200 lg [5, 9]. In the event of cardiac arrest,
recommendations from all sources align with the Advanced
Life Support guidelines including administration of
intravenous adrenaline [14].
The Resuscitation Council UK has collaborated with the
newly formed Peri-operative Allergy Network [15] and this
will likely include a specific peri-operative algorithm which
promotes early use of intravenous adrenaline by
anaesthetists in cases of suspected anaphylaxis. The
threshold blood pressure at which chest compressions
should be started was discussed in NAP6 and a systolic
blood pressure < 50 mmHg was recommended [16]. It was
emphasised that this should be in conjunction with, and not
to the detriment of, other treatments. This threshold has
subsequently been adopted by others [5, 7, 17].
Despite the differences in the methodologies of NAP6
and NAP7, and in view of the evolution of recommendations
and controversies, the collection of a national cohort of peri-
operative anaphylaxis cases leading to cardiac arrest or
death, separated by the learning brought about by NAP6,
gives a unique opportunity to assess how peri-operative
management and outcomes may have changed over this
period. Here we present data from patients suspected to
have developed grade 4 and 5 peri-operative anaphylaxis in
both cohorts.
Methods
The methods of NAP7 have been described in detail
previously [1]. In brief, all NHS hospitals and a subset of
independent sector hospitals undertaking anaesthesia care
in the UK were invited to participate. A network of local
coordinators was established to provide leadership and
oversight of the project in each hospital.
There were three phases. First, a baseline survey to
explore departmental and individual preparedness for and
experiences of peri-operative cardiac arrest [18, 19].
Second, a national activity survey examining anaesthetic
practices and complications in all cases undertaken in NHS
hospitals over four days [20, 21]. This survey also provided a
denominator for the study, with an estimated 2.71 million
anaesthetic interventions annually in the UK [20]. Third, a
registry of case reports of peri-operative cardiac arrest
including cases occurring from first anaesthetic contact until
24 h after discharge from immediate anaesthesia care [22].
Detailed anonymised structured case reports were
submitted and each was reviewed by a panel of clinicians
and lay representatives. The included cases formed the
numerator phase of the study. The review enabled
quantitative and qualitative analyses.

Cook et al. | Cardiac arrest due to suspected anaphylaxis in NAP7
As part of the case review, cases were classified by
areas of importance enabling topic-specific analysis (with
associated numerator and denominator data). The main
results [23, 24] and the full project are published separately
[10].
Results
In the baseline survey, anaesthetists estimated that
anaphylaxis is one of the four most frequent causes of peri-
operative cardiac arrest [19]. Among the peri-operative
cardiac arrests they had most recently attended,
anaesthetists reported anaphylaxis as the second most
common cause, accounting for 10% of cases [19]. The
median systolic blood pressure at which anaesthetists
reported they would start chest compressions was 41–
50 mmHg, with a tendency to initiate compressions at a
higher blood pressure in a patient of ASA physical status 3
compared with ASA physical status 2.
In the activity survey, of approximately 24,000 cases,
nine cases of suspected anaphylaxis were reported
(approximately 1 in 2700), eight during general anaesthesia
and one during regional anaesthesia, including seven cases
of severe hypotension and two of severe bronchospasm.
Two cases included cardiac arrest (peri-operative
anaphylaxis induced cardiac arrest rate of approximately 1
in 12,000), both of whom survived. As these cases were
reported at the point of care and not subject to classification
of severity or verification by clinical review or investigation,
any overdiagnosis of anaphylaxis would lead to an
overestimated incidence.
In the registry phase, there were 59 cases in which the
reporter either stated anaphylaxis was the cause of
the cardiac arrest or considered as a differential diagnosis.
Of these 59 cases, the panel considered 35 (59%) to be a
case of anaphylaxis and panel confidence in this diagnosis
was high in 19, moderate in 14 and low in 2. Other
diagnoses included isolated severe hypotension (8, 12%);
severe hypoxaemia (7, 12%); bronchospasm or obstructive
ventilation (5, 8%); and high neuraxial block (1, 2%).
There were four cases in which severe bronchospasm
was considered the primary diagnosis rather than
anaphylaxis. All patients recovered after a brief cardiac
arrest and did not require prolonged specific management
of bronchospasm or anaphylaxis. In one case, a patient with
airway disease was reported to have a flat capnograph trace
despite no initial cardiovascular disturbance; this resolved
rapidly with the treatment of bronchospasm with
adrenaline, without removal of the tracheal tube. In another
case, difficult ventilation and cardiac arrest were associated
with a flat capnograph, which resolved with tracheal
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Anaesthesia 2024
reintubation. The panel judged this may have resulted from
oesophageal intubation. All patients survived the cardiac
arrest. Three patients were discharged without harm or
delay and one died postoperatively, but it was unclear
whether that was related to the event. This would probably
have been an unexpected death. It was not clear in all cases
that tracheal intubation was a necessary part of general
anaesthesia.
In the 26 cases with a panel judgement of an erroneous
or unlikely diagnosis of anaphylaxis, care before cardiac
arrest was judged good by the panel in seven (27%) and
poor in three (23%). Overall care was judged good in 12
(45%) of these cases but 9 (35%) had elements of poor care
and there were high levels of uncertainty in assessments.
Three of these patients died and four were harmed. None of
the deaths were judged inevitable. In 16 of these cases,
panel confidence in the diagnosis was low.
The 33 cases judged to be anaphylaxis with high or
moderate confidence form the basis of further analysis. Of
these cases, 12 had a confirmatory tryptase result when
reported to NAP7 (Table 1). When compared with NAP6
cases, NAP7 cases were generally similar in terms of patient
characteristics; timing of cardiac arrest; initial cardiac
rhythm; duration of cardiac arrest; dose of adrenaline
administered; and requirement for critical care admission.
Compared with patients in the activity survey, those
experiencing anaphylaxis and cardiac arrest were more
likely to be obese, without frailty and undergoing elective
surgery. Patents aged 66–75 y were somewhat
overrepresented, but this was seen in no other age group
and may have occurred by chance. There was no pattern in
terms of patient sex, ethnicity, ASA physical status or timing
of surgery. The cases were spread across 15 different
surgical specialities, with none especially prominent.
Twenty-four (72%) cases presented at induction of
anaesthesia or in the period before surgery started (Fig. 1).
Three cases (9%) occurred in awake or sedated patients
including one case (3%) after surgery. Of the three
patients who were not receiving general anaesthesia at the
time of suspected anaphylaxis, two had respiratory
symptoms (one each of difficulty breathing and tongue
swelling) and all had profound hypotension as part of
presentation. In these cases, an antibiotic was the suspected
trigger drug. Anaphylaxis was more likely to occur in the
anaesthetic room compared with other causes of cardiac
arrest (10, 30% vs. 85, 11%) and 4 (13%) occurred in
potentially isolated locations.
In patients with cardiac arrest due to suspected
anaphylaxis, initial rhythm was more commonly pulseless
electrical activity (31, 94%) than in cases of cardiac arrest
3
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Anaesthesia 2024 Cook et al. | Cardiac arrest due to suspected anaphylaxis in NAP7

Table 1 Characteristics of peri-operative cardiac arrest due when the systolic blood pressure was < 50 mmHg, and
to anaphylaxis in NAP6 and suspected anaphylaxis in NAP7. once even when it was unrecordable.
NAP6 NAP7 Dosing of adrenaline varied, but in most cases was given
n = 40 n = 33
in 50–100 lg aliquots with good effect. Total median (IQR
Patient characteristics [range]) adrenaline dose was 2 (2–3 [1–9]) mg. There were no
Female 26 (65%) 21 (64%) reports of arrhythmias or other complications of
Age > 65 y 15 (38%) 15 (45%) administering intravenous adrenaline to manage peri-
ASA physical status 3–5 12 (31%) 12 (36%) operative anaphylaxis. In one case, a relatively healthy patient
BMI > 30 kg.m-2 22 (55%) 12 (38%) showed signs of anaphylaxis shortly after induction of
Timing anaesthesia. The patient received intramuscular adrenaline,
Before surgery 26 (81%) 24 (72%) but this did not prevent cardiac arrest. When a modest dose
Rhythm of intravenous adrenaline was administered, recovery was
Pulseless electrical activity 34 (85%) 31 (94%) prompt and the panel judged that earlier intravenous
Ventricular fibrillation or 4 (10%) 1 (3%) adrenaline might have prevented the cardiac arrest.
ventricular tachycardia All 33 patients were resuscitated successfully. All were
Asystole 2 (5%) 0 admitted to a high-dependency care area after the event, the
Bradycardia 0 1 (3%) vast majority with an unplanned admission to an ICU.
Adrenaline Duration of ICU stay was most commonly 1–3 days but
Mean dose of adrenaline; 5 2 included cases exceeding one week. Physical consequences
mg
of peri-operative anaphylaxis were relatively few. However,
Maximum dose of 13 9
reports included prolonged ICU stay; acute kidney injury;
adrenaline; mg
need for coronary artery stenting; and mood changes
Drug-induced arrhythmia 0 0
requiring psychological support. Recovery was generally
Short duration* 24 (60%) 21 (64%)
good with only two patients reported to have an increase in
Outcome
their modified Rankin Scale score of disability at discharge.
Return of spontaneous 35 (88%) 33 (100%)
circulation The one death occurred in a moderately healthy patient
Survival (when reported) 31 (78%) 32 (97%) where cardiopulmonary resuscitation was not started
Harm in survivors 10 (32%) 4 (13%) immediately when systolic blood pressure fell below
Suspected or confirmed culprit drug** 50 mmHg. The patient survived resuscitation but required
Antibiotic 21 (53%) 10 (62%) vasopressor support, admission to ICU and died of multi-
Neuromuscular blocking 16 (40%) 5 (31%) organ failure.
drug Compared with other causes of cardiac arrest reported
Chlorhexidine 2 (5%) 0 to NAP7, anaphylaxis had a higher rate of survival both at
Other 1 (3%) 1 (6%) initial resuscitation (33, 100% vs. 623, 74%) and (when these
Post-resuscitation care data were available) at discharge from hospital (24, 96% vs.
Admitted to critical care 28 (90%) 33 (100%) 360, 50%). Cases of anaphylaxis-induced cardiac arrest had
Recurrence of symptoms 0 0 a higher survival rate in NAP7 than in NAP6. In NAP7 33
Quality (100%) patients were resuscitated successfully and 32 (97%)
Overall care judged good 21 (53%) 26 (79%) survived to the point of reporting to NAP7, compared with
34 (85%) and 30 (75%), respectively.
*In NAP6, short duration cardiac arrest was defined as < 8 min
and in NAP7 as < 10 min. Of 24 patients with a final reported outcome, 20 (83%)
**In NAP7, 16 patients had a suspected or confirmed culprit experienced no harm beyond delayed discharge, a higher
drug reported.
proportion than other NAP7 cases due to other causes (285,
79%). Among these 24 patients, one patient died and three
came to harm, whereas among 40 patients reported to
from other causes (425, 50%). Four (12%) patients received NAP6 who had a cardiac arrest, 20 came to harm or died.
defibrillation. Duration of cardiac arrest was similar to that of Among the 33 cases reported to NAP7, care was rated
the whole NAP7 population, with 21 (64%) lasting < 10 min good before, during and after cardiac arrest in 26 (79%), 29
and 5 (15%) > 20 min. In a small number of cases, the panel (88%) and 29 (88%) cases, respectively. Cases with elements
judged there was a delay in starting chest compressions of poor care (i.e. rated poor or good and poor) totalled

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Cook et al. | Cardiac arrest due to suspected anaphylaxis in NAP7
Figure 1 Peri-operative timing of cardiac arrest due to anaphylaxis. PACU, post-anaesthesia care unit.
three before, four during and three after cardiac arrest,
respectively. Overall quality of care was rated good in 26
(79%) cases and there were elements of care rated poor in
five cases, which was better than in non-anaphylaxis cases
(good care 438, 52%, elements of poor care 258, 30%).
Rating of care quality in NAP7 cases of suspected
anaphylaxis with cardiac arrest was generally more positive
compared with equivalent cases in NAP6: 79% good care
(NAP6 21, 53%); and 15% with elements of poor care (NAP6
11, 28%).
In a sensitivity analysis, we included all 59 cases
reported to NAP7 as anaphylaxis: four deaths represent a
7% mortality rate and overall care was rated as good in 38
(64%) cases and elements of poor care were noted in 9
(15%) cases.
In 16 cases, a trigger drug was proposed (Table 1). No
cases occurred due to drug error (e.g. administering a drug
to a patient known to be allergic to that drug). In one case,
after a previous collapse following administration of an
antibiotic, an elevated tryptase was recorded but this was
not acted on. Subsequent administration of a related
antibiotic led to peri-operative anaphylaxis and cardiac
arrest requiring relatively brief cardiopulmonary
resuscitation. In another case, administration of an antibiotic
was followed by anaphylaxis, cardiac arrest and a hospital
admission lasting more than a week. A previous
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Anaesthesia 2024
antibiotic-related rash was not declared by the patient
before surgery but was subsequently identified in general
practice notes.
The incidence of cardiac arrest due to suspected
anaphylaxis in NAP7 was 33 in 2.71 million anaesthetic
interventions, an incidence of 1 in 82,000 (95%CI 1 in
58,000–100,000). Mortality from cardiac arrest due to
suspected anaphylaxis in NAP7 was 1 in 2.71 million (95%CI
1 in 486,000– > 10,000,000).
Discussion
The case registry identified 33 cases of cardiac arrest due to
suspected peri-operative anaphylaxis in NAP7 over the one-
year reporting period. This is highly consistent with the 40
cases reported to NAP6, when taking account of the
estimated 15% fall in surgical activity between the NAP6 [25]
and NAP7 activity surveys [20]. Anaphylaxis accounted for
33 (4%) of 881 cases of peri-operative cardiac arrest and was
the seventh most common cause as judged by the review
panel.
The panel disagreed with the reporter’s opinion that
cardiac arrest was caused by anaphylaxis in about half of
reported cases. We used panel consensus to determine this
and did not use a formal diagnostic likelihood score (such as
that described by Hopkins et al. [6]) as data available in the
case review form were sometimes insufficiently complete
5

Anaesthesia 2024
for this. In all cases not judged to be anaphylaxis, the panel
identified another significantly more likely cause of patient
deterioration and cardiac arrest and in these cases, quality
of care was notably poorer than in other NAP7 cases.
Anaesthetists appear to overestimate the frequency of
anaphylaxis as a cause of peri-operative cardiac arrest. In
the baseline survey, anaesthetists ranked it among the top
four most common causes, but in cases reported to NAP7 it
was the seventh most frequent cause. They also suggested
anaphylaxis accounted for 10% of peri-operative cardiac
arrests but the panel judged it was a cause of only 4% of
cases reported to NAP7. It is likely hypotension due to
anaesthetic technique or patient physiological status,
isolated bronchospasm and airway complications may be
incorrectly diagnosed as anaphylaxis. This highlights the
importance of considering other diagnoses at the time of
peri-operative cardiac arrest and of serial measurement
of mast cell tryptase to confirm or refute the presumed
diagnosis [13].
Similarities in patterns of timing, location, initial cardiac
rhythm and precipitants between cases of peri-operative
cardiac arrest reported to NAP7 and those reported in
NAP6, suggest consistency between projects.
Anaphylaxis leading to cardiac arrest occurs in the
absence of general anaesthesia, postoperatively and in
isolated locations where anaesthetists may work as a solo
operator, reminding us that all anaesthetists should be
expert in the management of both anaphylaxis and cardiac
arrest.
Two cases of anaphylaxis appear to have been
avoidable. In one case, better processes and follow-up
should have identified the cause of a previous anaphylactic
event with elevated mast cell tryptase; it is likely that
investigation would have led to the identification of a trigger
drug and avoidance of a cardiac arrest during a subsequent
anaesthetic. In the second case, information about allergies
differed between hospital and general practice notes,
highlighting the potential value of integrated digital notes
accessible across healthcare sectors.
Before cardiac arrest occurred, adrenaline was
generally administered intravenously in doses ranging from
50–100 lg. Intramuscular adrenaline was sometimes co-
administered. During prolonged cardiac arrest, standard
dosing for that situation was seen. There were no
complications associated with intravenous adrenaline
administration, but there was one case of anaphylaxis
progressing from moderate hypotension to cardiac arrest
when only intramuscular adrenaline was administered. In
this case, the panel judged that cardiac arrest would likely
have been avoided by early use of intravenous adrenaline.
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Cook et al. | Cardiac arrest due to suspected anaphylaxis in NAP7
A recent Japanese study of less severe peri-operative
anaphylaxis (43 cases, only two with cardiac arrests)
reported more rapid and sustained improvements in
cardiovascular variables when adrenaline was given
intravenously rather than intramuscularly [26]. The
accompanying editorial also advocated for intravenous
over intramuscular administration [27].
Although care was rated generally as good, delays in
starting cardiopulmonary resuscitation were relatively
common and drew criticism from the panel. This included
not starting cardiopulmonary resuscitation when the systolic
blood pressure persisted below 50 mmHg despite initial
treatments, and even occasionally when it was
unrecordable. Of note, for the one patient who died of peri-
operative anaphylaxis, there was delay in starting
cardiopulmonary resuscitation and despite initial
resuscitation being successful, the patient died after
developing multi-organ failure.
Rating of care quality in NAP7 was generally improved
compared with NAP6. Outcomes from peri-operative
cardiac arrest due to anaphylaxis also appeared better in
NAP7 than in NAP6, with a 97% survival rate in NAP7
compared with 75% in NAP6. Overall, compared with NAP6,
NAP7 data tentatively suggest improvements in the care of
patients with cardiac arrest due to anaphylaxis and
improved outcomes.
Our analysis has some limitations. First, in comparing
NAP7 with NAP6, we are comparing different projects with
different inclusion criteria. While the NAP6 dataset was
designed specifically to explore detailed diagnosis and
management of peri-operative anaphylaxis, the dataset for
NAP7 was not. Because NAP7 was designed to examine all
causes of peri-operative cardiac arrest, it included
considerably less anaphylaxis-related detail. Patients
included in NAP6 had undergone thorough immunological
investigation to confirm or refute anaphylaxis and those in
NAP7 had not. Mast cell tryptase measurements were only
available at the point of reporting for a minority of cases in
NAP7 and were interpreted by local reporting teams.
Overall, this means it is plausible that in NAP7 we may have
excluded some true cases of anaphylaxis or included some
that were not. Second, the judging panels, despite using the
same methodology, did not comprise the same individuals
and may have applied judgements differently. To counter
these limitations, we have only compared NAP7 data with
reports in NAP6 who had a cardiac arrest. These
comparisons found the patient and event profiles to be
similar. Third, both datasets are small. We have compared
proportions between two datasets and have intentionally
not undertaken statistical analyses. Conclusions should

Cook et al. | Cardiac arrest due to suspected anaphylaxis in NAP7
Box 1 Recommendations from the 7th National Audit
Project of the Royal College of Anaesthetists relating to
peri-operative anaphylaxis.
National
• National guidance should be co-ordinated so that
guidance from the Resuscitation Council, Quick
Reference Handbook of the Association of
Anaesthetists and Peri-operative Allergy Network are
consistent for the route and initial dose of adrenaline
to administer for peri-operative anaphylaxis.
Institutional
• Organisations should have a mechanism to ensure
abnormal tryptase results are flagged to the
requesting clinician, to minimise the risk of avoidable
anaphylaxis in the future.
• Digital solutions should ensure recording of all
allergies is consistent across all healthcare records
and accessible to clinical staff.
• Departments of anaesthesia should have protocols
for the detection, management and referral for
investigation of peri-operative anaphylaxis. These
should be readily accessible to all departmental
members, widely disseminated and kept up to date.
Individual
• All clinical staff who deliver anaesthesia should be
skilled in the management of peri-operative
anaphylaxis and cardiac arrest.
• All clinical staff who deliver anaesthesia should be
expert in the administration of intravenous
adrenaline, both in low-dose bolus and as an infusion,
for the management of peri-operative anaphylaxis.
• Chest compressions should be started if the systolic
blood pressure falls and remains below 50 mmHg
during anaesthesia in an adult, in addition to
standard treatments for anaphylaxis.
therefore be interpreted cautiously. We believe the
importance of the topic, the opportunity NAP7 presents and
the impracticality of collecting a larger dataset justify this
approach, but we do acknowledge its limitations.
In summary, NAP7 has shown that peri-operative
cardiac arrest from anaphylaxis is rare, occurring in
approximately 1 in 80,000 anaesthetic interventions and
accounts for < 4% of peri-operative cardiac arrests.
Anaesthetists overestimate the frequency of anaphylaxis
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as a cause of peri-operative cardiac arrest and should
consider other diagnoses. In NAP7, care was generally
good and outcomes were better than for other causes
of peri-operative cardiac arrest. There is some evidence
from NAP7 that care of and outcome from peri-
operative cardiac arrest due to anaphylaxis has
improved in the UK over the last five years. The NAP7
report includes recommendations to improve the care of
patients experiencing anaphylaxis including cardiac
arrest (Box 1).
Acknowledgements
The project infrastructure was supported financially and
with staffing from the Royal College of Anaesthetists. Other
NAP7 panel and team members are: C. Bouch; J.
Cordingley; L. Cortes; M. T. Davies; J. Dorey; S. J. Finney; S.
Kendall; G. Kunst; J. Lourtie; D. N. Lucas; I. K. Moppett; R.
Mouton; G. Nickols; J. P. Nolan; F. Oglesby; V. J.
Pappachan; B. Patel; F. Plaat; K. Samuel; B. R. Scholefield; J.
H. Smith; C. Taylor; L. Varney; and E. Wain. We thank all
NAP7 local reporters and their teams and all UK
anaesthetists who completed surveys or submitted cases.
The NAP7 fellows’ salaries were supported by: South Tees
Hospitals NHS Foundation Trust (AK); Royal United
Hospitals Bath NHS Foundation Trust (EK); and NIHR
Academic Clinical Fellowship (RA). JS and TC’s employers
receive backfill for their time on the project (4 hours per
week). CB is the NAP7 panel representative for the
Independent Healthcare Providers Network and is
employed by Spire Health as an Associate Medical Director.
NAP7 panel members were not paid for their role. No other
competing interests declared.
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