Pediatric Anesthesia, Intensive Care and Pain: Standardization in Clinical Practice by Marinella Astuto

Author:Marinella Astuto
Language: eng
Format: epub
Publisher: Springer Milan, Milano

8.3 8.3 Allergy

Parents frequently indicate that their children have multiple drug allergies, though often these have not been validated. Parents confuse side effects with a true allergy. Potential allergic cross-reactivity between drugs and foods are frequently considered perioperative risk factors that need to be addressed. Allergenic cross-reactivity is a property defined by individual antibodies to other allergens with structural similarity and can be seen in families of drugs or agents used during the perioperative period. “Multiple drug allergy syndrome” or “multiple drug hypersensitivity” is a clinical condition characterized by the propensity to react to chemically unrelated drugs, mainly antibiotics [15]. In most cases, the syndrome presents as acute urticaria, angioedema, or both after administration of the allergenic compounds [15].

Immediate allergic hypersensitivity reactions are triggered by specific im- munological mechanisms mediated by antibodies [usually immunoglobulin E (IgE) isotype] and can lead to life-threatening symptoms [16]. The main risk factor for anaphylaxis is a previous uninvestigated severe immediate hypersensitivity reaction during the perioperative period. Neuromuscular blocking agents and antibiotics are the most common triggers. If possible, a history of drug-induced anaphylaxis should be confirmed by an appropriate evaluation wherever possible [16–20].

Many food allergies (egg, soy, peanut, seafood/fish, shellfish) are often mistakenly considered a contraindication to some medications, although the evidence 8 Anesthesia and Perioperative Medicine for this is lacking. Many false assumptions about drug allergies are mostly based on anecdotal case reports. The evidence suggests that egg-allergic, soy-allergic, or peanut-allergic patients are not more likely to develop anaphylaxis when exposed to propofol. Egg allergy is most common during childhood and is usually outgrown by adulthood [21]. Egg-allergic patients generally demonstrate immediate hypersensitivity to proteins from egg white (ovomucoid, ovalbumin), whereas lecithin, which is not the allergenic determinant, is found in the egg yolk. Propofol is marketed in an oil-in-water emulsion using soybean oil (10%) and egg lecithin (1.2%) as the emulsifying agents. The documented anaphylactic reactions are caused by the isopropyl or phenol groups in propofol rather than the lipid vehicle [22,23]. There is therefore little or no reason to contraindicate propofol in egg- allergic patients.

There is also little or no reason to contraindicate propofol in children with soy allergy or peanut allergy either. Soy allergy is an early-onset food allergy affecting approximately 0.4% of children. Most children develop tolerance by late childhood [24]. Refined soybean oil, such as that present in propofol, is safe for people with soy allergy because the allergenic proteins are removed during the refining process. Soy and peanuts are both leguminous plants and thus any cross-reactivity should not necessitate avoiding propofol.

Shellfish (crustaceans, mollusks) or fish are among the most common foods provoking severe anaphylaxis [25]. The major allergen in fish is the muscle protein parvalbumin, while tropomyosin is the major allergen in crustaceans. Shellfish allergens do not cross-react with fish allergens. Because the allergenic determinants for shellfish and fish are muscle proteins and not other components, such as iodine, there is no reason to modify the anesthetic protocol in cases of shellfish- allergic or fish-allergic patients. There

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