Reader response
Myron Yaster MD
From A. Michael Broennle MD retired
My experience with penicillin allergy & cefazolin
In ~1971 I was serving as an anesthesiologist at Wilford USAF Medical Center, San Antonio. After a few months I developed a chronic cough and was seen in the hospital’s medical clinic where an internist treated me with an oral penicillin. After a few days I developed a rash and was instructed to discontinue the penicillin. No workup of the rash was done and I then considered myself to be “allergic to penicillin.”
Approximately 10-15 years latter I underwent surgery for a torn meniscus. Preoperatively my orthopedic surgeon, my anesthesiologist who I had trained with, and I discussed choice of prophylactic antibiotic. I received cefazolin intravenously. Within minutes I develop urticaria and received intravenous Benadryl. The hives quickly resolved though over the next ~90 minutes I experienced chills/. The surgery was completed under spinal anesthetic...in retrospect I think I may have had a minor anaphylactic reaction.
Over the years I have had other surgical procedures and other conditions for which was I was given non-cephalosporins without side effects or postoperative infections.
From Greg Hammer MD
Penicillin (PCN) allergy is the most commonly reported drug allergy, with a reported prevalence of about 10% in the general population. In fact, the true prevalence is likely closer to 1% or even less.[1] True PCN allergy is an immediate hypersensitivity reaction mediated by IgE antibodies. The antibodies bind to the PCN molecule, triggering the immune response.
PCN allergy is over-diagnosed in part because most reported reactions are not mediated by IgE and therefore not true allergies. In addition, the IgE antibodies responsible for PCN allergy disappear over time. Approximately 50% of people with confirmed IgE-mediated PCN allergy lose their sensitivity within 5 years of the initial reaction, and about 80% of individuals are no longer allergic after 10 years.[2]
There is a myth that 10% of patients with PCN allergy have cross-reactivity with 1st- generation cephalosporins. In fact, the actual incidence of cross-reactivity with cefazolin, for example, is likely in the range of 1% or less.[3] Cross-reactivity with 2nd- and 3rd- generation cephalosporins is negligible. This is because these drugs lack the side-chain responsible for PCN allergy.
The bottom line is that older children with a history of PCN allergy are very unlikely to have an allergic response to penicillins and especially cephalosporins. It is reasonable to give a test dose of cefazolin while observing the skin prior to draping in patients with reported PCN allergy; this step may be skipped when administering 2nd- and 3rd- generation cephalosporins are being administered.
1. Gadde J, Spence M, Wheeler B, Adkinson NF, Jr.: Clinical experience with penicillin skin testing in a large inner-city STD clinic. Jama 1993, 270(20):2456–2463.
2. Trubiano JA, Adkinson NF, Phillips EJ: Penicillin Allergy Is Not Necessarily Forever. Jama 2017, 318(1):82–83.
3. Campagna JD, Bond MC, Schabelman E, Hayes BD: The use of cephalosporins in penicillin-allergic patients: a literature review. J Emerg Med 2012, 42(5):612–620.
From Catharine WILSON MBBS, FRCA, retired, SHEFFIELD CHILDREN’S NHS FOUNDATION TRUST)
I am a great fan of caudal blocks and as you say have found them consistently easy, reliable and effective throughout my career. Until now! I just spent 2 weeks in Sierra Leone with Mercy ships, doing paediatric orthopaedic lower limb procedures. GA/caudal as the standard recipe.
I found myself unable to find the caudal space in a significant number of the children (??25%, I didn’t actually count) and was getting quite embarrassed by how often I was saying “this doesn’t feel right” in front of the audience I didn’t know! As a disclaimer, I have avoided orthopaedics for most of my career, however I still think I have had more failures in 2 weeks than in the rest of my 35 years practice put together (25 of those being purely paediatrics).
I asked other colleagues if they had found this too in African children with bony dysplasia or rickets, or even just in orthopaedics compared to general surgery, on the basis that there is a bony problem to start with. As the paediatric specialist with the most caudal experience there however no-one else really knew. One colleague attempted to ultrasound a space I couldn’t find (I have never bothered with u/s for caudals, the landmarks are too obvious, usually), and we couldn’t see a space at all. I found one space by “digging” a lot and was surprised it worked. More luck than skill on that occasion I felt. I have done a very brief internet search and found nothing. Do any of the PAAD readers have any opinions or knowledge of this please?
From David F. Vener, MD. Professor, Department of Anesthesiology, Perioperative and Pain Medicine, Arthur S. Keats Division of Pediatric Cardiovascular Anesthesiology, Texas Children’s Hospital/Baylor College of Medicine, Houston, TX
Thank you for reviewing the most recent central line placement data showing the dramatic impact of ultrasound guidance on minimizing complications. Congenital cardiac anesthesiologists place by far the greatest number of central lines in the pediatric population on a routine basis and ultrasound guidance is the de facto standard of care regardless of location of placement. The subclavian approach is relatively uncommon for a number of reasons: 1) access to the line to inspect and ensure it has not moved is limited, 2) there are multiple reports, including my own personal experience, of the line being trapped between the first rib and clavicle and occluded when the sternal retractor is in place, preventing you from administering medications or accurately monitoring central venous pressure, and 3) the slightly increased risk of hemo- or pneumothorax during placement even with ultrasound. For that reason, either internal jugular or femoral placement tends to dominate depending upon the age of the patient and the institutional bias. The Congenital Cardiac Anesthesia Society – Society of Thoracic Surgery Congenital Heart Surgery Database tracks both placement location and complications in congenital heart surgery patients. A recent 4 yr report from the database shows the following national data: Neonates – Internal Jugular 31.4% (n=4255), Femoral 13.3% (n=1804), Subclavian 0.7% (n=94). In 6.3% (n=860) of neonates the surgeon places the central line directly into the right atrium at the conclusion of surgery and tunnels it out through the chest wall); Infants – IJ 49.9% (n=11810) , Femoral 14.3% (n=3377), Subclavian 1.1% (n=249); Children – IJ 61.8% (n=16209), Femoral 6.2% (n=1614), Subclavian 1.5% (n=388); Adults – IJ 72.4% (n=3699), Femoral 3.4% (n=176), Subclavian 1.6% (n=83). In this same 4 yr reporting period out of tens of thousands of lines there were 2 reported cases of pneumothorax with central line placement and 17 reported cases of vascular compromise with central line placement (typically a dusky or mottled lower extremity).