Speakers
Dr. Rowena LEE
Associate consultant
Department of Anaesthesiology and Perioperative Medicine
Hong Kong Children’s Hospital
Rowena is paediatric anaesthesiologist. Her profound interest in paediatric anaesthesia grew from her training years in Queen Elizabeth Hospital (QEH). In 2016, she did her fellowship in Children Hospital in Westmead, Sydney. She joined Hong Kong Children’s Hospital (HKCH) in 2019, in which she further trained in paediatric cardiac anaesthesia.
She loves challenges and enjoys exploring different areas in anaesthesia. She loves airway management, in both adults and paediatrics. She has been instructor or speaker for various airway courses in Hong Kong and overseas. She advocates institutional preparedness for ‘cannot intubate, cannot ventilate’ situations and has implemented CICO packs in both QEH and HKCH.
Rowena is an experienced trainer for various anaesthetic / non-anaesthetic related courses. She set up in-situ simulation training for her department on crew resource management and perioperative resuscitation.
In recent two years, she starts to explore perioperative allergology. She has been working closely with an allergist in HKCH on perioperative anaphylaxis investigations, during which she had experience in drug provocation test and achieved the world’s first neuromuscular blocking agent desensitization.
“It's what we think we know that keeps us from learning.” Claude Bernard
What we may have known-
Perioperative anaphylaxis is IgE mediated mast cell activation causing cardiorespiratory and cutaneous symptoms which can be life threatening. Adrenaline is the first line treatment in international guidelines. Referral to allergist for Investigation to identify allergens is crucial to avoid future anaphylaxis. Skin test is commonly used. Neuromuscular blocking agents (NMBAs) are common culprits and cross sensitivity among different NMBAs exists.
What we may not know-
Anaphylaxis is usually IgE-mediated but other pathways, including complement activation and MRGPRX2 surface receptors of mast cells exist. With various mechanisms behind, skin tests may be negative. Clinical history must be taken into consideration while interpreting skin tests. Doubtful results should be communicated with allergists and verified. In-vitro tests, such as basophil activation tests and allergen specific Immunoglobulin E are gaining popularity but need further validation for anaesthetic drugs. Drug challenge is the gold standard, yet carries high risk. Anaesthesia may be required in NMBA challenge. Decision to challenge should be scrutinized and should only be done in specialized centre with close collaboration between allergy and anaesthesia team. While avoidance of known allergens is the safest, it may not be feasible for patients sensitized to multiple agents. Desensitisation may be an option when the allergen is the only / preferred drug to use.
I will illustrate how we tackled the challenge in investigation on perioperative allergy in a complex syndromic paediatric patient sensitized to multiple NMBAs. I will also describe how we achieved the world’s first desensitization of neuromuscular blocking agent for a series of technically challenging surgery. (I would like to express my gratitude to all the support from Professor Mariana Castells and the team in Harvard Medical School Drug Hypersensitivity and Desensitistaion Centre).
