Lisa Bagley, Anna Kordun, Sean Sinnott, Kimberly Lobo, Joseph Cravero. Food allergy history and reaction to propofol administration in a large pediatric population. Paediatr Anaesth. 2021 May;31(5):570-577. PMID: 33529424
I honestly don’t think my kids would have survived elementary school if they were school aged today because peanut butter (creamy ONLY!) was about the only thing they ate. Which brings us to today’s paper and the implications of widespread food allergy in the U.S. population and anesthetic practice. How widespread? “Current estimates indicate that 4%-8% of American children are diagnosed with food allergy with more than 40% having experienced severe allergic reaction. The Food and Drug Administration (FDA) has designated eggs, peanuts, tree nuts, and soybeans as major food allergens”. I think you all know where this is going: When using propofol in these patients “is it safe”? (my apologies to the movie and book Marathon Man by William Goldman).
In this large (232,392 anesthetics) retrospective study in one institution (Boston Children’s Hospital), evidence of allergic reaction to propofol during anesthesia was evaluated and compared with a large nonallergic cohort who received propofol. In the large cohort labeled with food allergic, the majority had no formal allergy testing or actually had negative testing. The good news: the authors found no evidence of a relationship between food allergy history and perioperative propofol reaction (which was in any case quite rare). They concluded that “multiply allergic and atopic patients are not at risk of a propofol reaction or not in any more risk than patients not labeled with food allergy”.
Unfortunately, the product label specifically states that propofol is contraindicated in patients allergic to eggs, soybeans, or soy. Oh Oh! As discussed in the previous PAAD regarding NPO guidelines, bucking the package insert or medical society guidelines may place you, the practitioner, in potential medical legal jeopardy. As the authors state: “Our data suggests the need to revisit propofol labeling contraindications for patients with egg, and soy allergies. We also encourage stronger policies, better allergy descriptions, and perhaps inclusion of allergist involvement when listing an allergy in the medical record of pediatric surgical patients”. My view: “Good luck”! I wish Ron was alive…this was an area of his exceptional expertise. So, I will throw this out to the PAAD readership, if any of you have this kind of expertise please get in touch with John and me so we can tap into your skill sets…
OK, one final thought. Severe allergy or anaphylaxis to some drug will happen with or without a history of food allergy. When life-threatening, critical events occur in the operating room there is often little time to think or deliberate about treatment options. Success often depends on implementing a team approach with well-rehearsed, systematic, evidence-based assessment and management protocols within the first moments of presentation. Yet, because life-threatening crises are rare and human performance can be compromised under stressful conditions, even expert clinicians may omit or delay key actions, with detrimental effects on patient morbidity and mortality. In multiple simulation-based studies, correct performance of key actions increased when emergency manuals, crisis checklists, or cognitive aids were used.1 Because of this, the Society for Pediatric Anesthesia has developed the Pedi Crisis V 2 mobile app which works on both Apple and Android cell phones.2 If you haven’t already downloaded this app (it’s free for SPA and non-SPA members) go to the app store as soon as you finish reading this PAAD and download it!
Myron Yaster MD
1. Marshall S: The use of cognitive aids during emergencies in anesthesia: a review of the literature. Anesth Analg 2013; 117: 1162-71
2. Clebone A, Strupp KM, Whitney G, Anderson MR, Hottle J, Fehr J, Yaster M, Schleelein LE, Burian BK, Galvez JA, Lockman JL, Polaner D, Barnett NR, Keane MJ, Manikappa S, Gleich S, Greenberg RS, Vincent A, Oswald SL, Starks R, Licata S: Development and Usability Testing of the Society for Pediatric Anesthesia Pedi Crisis Mobile Application. Anesth Analg 2019; 129: 1635-1644