Anaesthetic management of patients with pre-existing allergic conditions: a narrative review

Abstract

This narrative review seeks to distinguish the clinical patterns of pre-existing allergic conditions from other confounding non-allergic clinical entities, and to identify the potential related risks and facilitate their perioperative management. Follow-up investigation should be performed after a perioperative immediate hypersensitivity to establish a diagnosis and provide advice for subsequent anaesthetics, the main risk factor for perioperative immunoglobulin E (IgE)-mediated anaphylaxis being a previous uninvestigated perioperative immediate hypersensitivity reaction. The concept of crossreactivity between drugs used in the perioperative setting and food is often quoted, but usually not supported by evidence. There is no reason to avoid propofol in egg, soy, or peanut allergy. The allergenic determinants have been characterised for fish, shellfish, and povidone iodine, but remain unknown for iodinated contrast agents. Iodinated drugs may be used in seafood allergy. Evidence supporting the risk for protamine allergy in fish allergy and in neutral protamine Hagedorn insulin use is lacking. Conversely, cross-reactivity to gelatin-based colloid may occur in a-gal syndrome.Atopy and allergic asthma along with other non-allergic conditions, such as NSAID-exacerbated respiratory disease, chronic urticaria, mastocytosis, and hereditary or acquired angioedema, are not risk factors for IgE-mediated drug allergy, but there is a perioperative risk associated with the potential for exacerbation of the various conditions.

Perioperative anaphylaxis: pathophysiology, clinical presentation and management

“…NSAIDs). 8 Non-allergic immediate hypersensitivity such as histamine release induced by NMBAs (e.g. atracurium, mivacurium, suxamethonium), propofol, or both in young, atopic, stressed, or all three patients is usually mild-to-moderate, while those induced by vancomycin or other antibiotics (e.g.…”

“…There is no evidence showing a higher prevalence of either non-allergic or IgE-mediated druginduced immediate hypersensitivity in mastocytosis when compared to the general population. 8 Perioperative management of mastocytosis has been detailed elsewhere. 9…”

Food, fads, allergies and anaphylaxis with propofol

“…Food allergies may be problematic for some drugs (e.g. alpha‐gal syndrome, an IgE‐mediated red meat allergy and gelatin‐based colloid) , although many of these reported relationships have scant supportive data, for example, fish or shellfish allergy and iodine, fish and protamine, neuromuscular blocking drugs and pholcodine (morpholinylethylmorphine) . The supposition that genuine serious allergic reaction to propofol is rare and is not reliably predicted by a history of food allergy in children is a conclusion reached by others .…”

“…Anaphylactic reactions to propofol certainly occur, but are possibly more related to the phenyl nucleus and the isopropyl groups or ethylenediaminetetraacetic acid (EDTA) contained in the formulation . The incidence of allergic reactions to propofol in children remains uncertain.…”

Soja-Allergie und Propofol – überschätzt oder relevantes Problem?

“…Bedenkt man dann noch, dass eine klare Zuordnung vieler häufig zu beobachtender perioperativer Symptome (diskretere Atembeschwerden, Blutdruckabfall, Erbrechen, Flush) als allergisch oder pharmakologisch/irritativ zumeist nicht möglich ist, wird die Schwierigkeit zu dieser Fragestellung eine eindeutige Antwort auf Basis einer epidemiologischen Studie zu geben, deutlich. Vor diesem Hintergrund sind die Ergebnisse der aktuellen Studie sicherlich dennoch sehr hilfreich und geeignet die Empfehlung zu stützen, auf den Einsatz von Propofol nicht einfach zu verzichten, weil eine Hühnerei-, Soja-oder Erdnussallergie vorliegt [2].…”