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A 10-year-old girl with chronic abdominal pain is presenting for an upper endoscopy and biopsies because of abdominal pain. She has multiple allergies, including penicillin, soy, eggs, and nuts, all causing anaphylaxis. She has never required general anesthesia before.
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PREOPERATIVE CONSIDERATIONS
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Patients with multiple allergies may be at risk for allergies to any product they come in contact with. In particular, propofol is manufactured with soy oil and egg lecithin/phosphatide, and there are concerns regarding its use in children with egg and soy allergies. It is unlikely that patients who are able to tolerate cooked eggs will react to propofol, as the heating process may denature some of the allergenic proteins, and this may also be the case during propofol manufacturing. There are only two published cases of patients with egg allergy who have suffered an allergic reaction to propofol, and most documented cases of propofol allergy were to the isopropyl or phenol group rather than the lipid vehicle. That being said, the package inserts in Australia and the United Kingdom list allergies as relative contraindication to the use of propofol (egg/soy in Australia, soy/peanut in the United Kingdom).
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ANESTHETIC MANAGEMENT
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Propofol may be used.
If you choose to avoid propofol, you have multiple options: Sevoflurane induction and maintenance after endotracheal intubation, midazolam/ketamine/dexmedetomidine combinations (midazolam 0.1 mg/kg; ketamine 1 mg/kg/dose, titrate to effect; dexmedetomidine 0.2-0.5 mcg/kg/h).
There is no evidence that pretreatment with antihistamines or corticosteroids will prevent allergic reactions in patients with severe allergies.
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POSTOPERATIVE CONSIDERATIONS
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Be aware of your patient’s risk for allergic reactions and ensure her return to baseline before discharging her home.
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DOs and DON’Ts
✓ Do be aware that egg allergy is not a contraindication to the use of propofol.
✓ Do know that there are plenty of suitable alternatives should you choose to avoid propofol.
⊗ Do not premedicate patients with allergies to avoid allergic reactions.
✓ Do keep anaphylaxis in mind in any patient presenting with bronchospasm and hypotension.
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Despite the product being the same, manufactured by the same company, package inserts for Diprivan 10% in Australia and the United Kingdom list food allergies as a relative contraindication to the use of propofol (egg/soy in Australia, soy/peanut in the United Kingdom), while there are no such warnings in the United States.
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The first documented anaphylactic death occurred in 2641 BC when Menes, an Egyptian pharaoh, died after a wasp or bee sting.