Propofol Use in Children with Allergies to Egg, Peanut, Soybean, or Other Legumes
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Design
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Retrospective study
N= 1,196
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Objective
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To assess the safety of propofol in children with egg, peanut, soybean, or legume allergy, or sensitivity, in a larger cohort than previously examined and also to compare the rates of potential allergic reaction in food-allergic children with those in children without food allergies
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Study Groups
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Allergic group (n= 304)
Control group (n= 892)
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Inclusion Criteria
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Children with immunologically confirmed egg, peanut, soybean, or legume allergy and who underwent general anesthesia with propofol at Princess Margaret Hospital for Children in Australia.
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Exclusion Criteria
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Not explicitly stated.
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Methods
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The study extracted details regarding allergy diagnosis, each anesthetic administered and any adverse events or signs of an allergic reaction in the peri-operative period. A convenience sample of patients without any known food allergies was identified from a prospective anesthesia research database and acted as a control group.
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Duration
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Between 2005 to 2015
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Outcome Measures
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Allergic reactions
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Baseline Characteristics
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Allergic group (n= 304)
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Control group (n= 892)
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Age, years
median (IQR [range])
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5.0 (2.7 – 8.8 [0.0 – 18.0])
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6.0 (3.9 – 9.6 [0.0 – 17.0])
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Weight, kg
median (IQR [range])
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18.6 (13.6 – 28.3 [3.1 – 88.7])
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22.5 (16.5 – 36.3 [2.3 – 121.0])
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ASA physical status
1
2
3
4
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183 (28.2%)
298 (46.0%)
163 (25.2%)
4 (0.6%)
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524 (58.7%)
351 (39.3%)
16 (1.8%)
0
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Total propofol dose, mg
median (IQR [range])
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80 (40 – 140 [4 – 1442])
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50 (30 – 140 [4 – 2250])
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Total propofol/kg body weight, mg*kg-1
median (IQR [range])
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4.0 (2.4 – 5.4 [0.4 – 40.0])
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2.4 (1.3 – 4.3 [0.2 – 29.9])
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Anesthesia duration, min
median (IQR [range])
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39 (24 – 64 [8 – 322])
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47 (33 – 68 [6 – 1424])
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Recovery area duration, min
median (IQR [range])
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35 (28 – 45 [11 – 166])
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40 (31 – 52 [11 – 1408])
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Results
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Summary of diagnosed allergy, medical history, nature of suspected reaction and clinical impression in ten patients with possible reactions following propofol exposure
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Case
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Allergy |
Other allergies, atopy |
Background medical information |
ASA physical status |
Reaction sign |
Treatment |
Possible cause |
1
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Egg white
Egg yolk
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EMLA, dressing, hayfever |
GEFS+, SCN1 Mutation, PEG fed, rhinoconjunctivitis |
3 |
Tachycardia |
- |
Sepsis |
2
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Egg white
Egg yolk
Peanut
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Tegaderm dressing |
Wiskott–Aldrich Syndrome |
2 |
Stridor |
- |
Stridor after every tracheal intubation |
3 |
Egg white
Peanut
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Cefaclor, shellfish |
Asthma, rhinoconjunctivitis |
2 |
Mild audible wheeze without oxygen desaturation |
- |
Asthma, current upper respiratory infection, wheeze directly after tracheal extubation |
4 |
Egg white
Egg yolk
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- |
Juvenile myelomonocytic leukemia |
3 |
Generalized skin rash, cough
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Promethazine 7.5 mg |
Platelet infusion reaction. Tolerated propofol without any adverse event in five following procedures |
5 |
Peanut |
Ceftazidime
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CF, asthma, eczema, rhinoconjunctivitis, MBL deficiency |
3 |
3x cough |
CPAP |
After CT scan + bronchoscopy |
6 |
Egg white
Egg yolk
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Mosquito bite |
OSA, asthma, syringomyelia, MBL deficiency |
3 |
Cough |
4 mg Dexamethasone 10 mg Loratadine postop |
After two tracheal intubation attempts |
7 |
Egg white
Egg yolk
Peanut
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Fentanyl, oxycodone, tapes, cow’s milk, chicken, kiwi fruit |
VACTERL syndrome premature, single right dysplastic kidney, eczema |
3 |
Localised skin rash on operation side |
- |
Reaction to Betadine |
8 |
Egg white
Egg yolk
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- |
OSA |
2 |
Brief oxygen desaturation to 85% |
CPAP |
OSA |
Possible reaction causes
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9 |
Egg white
Egg yolk
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- |
Born at 28 weeks gestation, chronic lung disease, bronchomalacia, gastroschisis, short gut syndrome, PEG & TPN-fed |
3 |
Facial swelling (peri-oral and peri-orbital) |
60 mg Hydrocortisone 3 mg Promethazine |
Likely intralipid reaction given previous history of facial swelling with TPN |
10 |
Egg white
Egg yolk
Peanut
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Whitefish, grass |
Asthma, rhinoconjunctivitis, eczema |
2 |
Oxygen desaturation to 90%, wheeze |
2 x 2.5 mg Ventolin, CPAP |
Atelectasis and mild bronchospasm following extubation |
EMLA: eutectic mixture of local anaesthetic; GEFS+: Genetic epilepsy with febrile seizures plus; CF: cystic fibrosis; MBL deficiency: Mannose-binding lectin deficiency; CPAP: Continuous Positive Airways Pressure; OSA: obstructive sleep apnoea; VACTERL: Vertebral anomalies, anal atresia, cardiac defect, tracheo-esophageal fistula, renal abnormalities, limb abnormalities; TPN: total parenteral nutrition.
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In 10 (3%) allergy patients and 124 (14%) allergy-free patients, criteria for a possible allergic reaction were met. In nine of the food-allergic children and in all the controls valid non-allergic explanations for the clinical symptoms were found. One likely mild allergic reaction was experienced by a food-allergic child with a previous history of intralipid allergy
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Adverse Events
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See "Results"
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Study Author Conclusions
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We conclude that a genuine serious allergic reaction to propofol is rare and is not reliably predicted by a history of food allergy.
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InpharmD Researcher Critique
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Given the retrospective nature of the study, the study assumed an allergy for every positive reaction on skin prick testing or IgE testing, which may not always equate with a clinical allergy. Moreover, only 132 (43%) of 304 children in allergic group were exposed to propofol within one year after positive testing, and it is likely that some may have lost their clinical reactivity between testing and propofol exposure.
For two possible reaction causes, patients were not further tested to determine whether the reaction was due to propofol sidechains or the food component.
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