Propofol and egg allergy

[coprolalia]

Okay, so I get into an argument yesterday with an attending (imagine that). This attending wants to avoid propofol in a 15-month-old who has an egg allergy.

I say, "There's no egg in propofol." I've run into this scenario before a while back and gave propofol with no problems.

Then, this attending says (basically), "You are stupid. You need to do more reading. Of course there's egg in propofol." We're off site and the attending wants to use ketamine and a whole host of other meds to keep this kid sedated while this minor procedure is done. Kid is going home immediately afterwards.

I look it up. I'm wrong. There's egg lecithin in Diprivan that is extracted from the yolk. I was pretty sure that there wasn't any in generic propofol, but I'm big enough to admit that there is and I was mistaken. It's there as a cheap, easy to obtain source of phosphatidylcholine.

So, what's the right answer? What would you do? Use propofol in a kid with an egg allergy or not? I'll tell you what we ended up doing later.

-copro

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[jetproppilot]

I've always avoided propofol when someone has an "egg allergy".

Whether or not its really needed I dont know.

As an aside, seems it'd be easier to do a sevo induction with a 15 month old where no intravenous induction agent is needed unless there were full stomach concerns.

 

[coprolalia]

As an aside, seems it'd be easier to do a sevo induction with a 15 month old where no intravenous induction agent is needed unless there were full stomach concerns.

We did a sevo mask to put the IV in. Maintenance was a separate issue.

-copro

 

[jetproppilot]

We did a sevo mask to put the IV in. Maintenance was a separate issue.

-copro

Why do you need an IV induction agent after the IV is in? Use deep inhalation anesthesia for intubation, plus/minus muscle relaxant, then maintain with volatile agent...and some fentanyl if you like.

No need for propofol/ketamine etc

 

[coprolalia]

Why do you need an IV induction agent after the IV is in? Use deep inhalation anesthesia for intubation, plus/minus muscle relaxant, then maintain with volatile agent...and some fentanyl if you like.

No need for propofol/ketamine etc

Didn't intubate. Masked the kid, put in the IV, then maintained with another agent. Kid had no airway and was spontaneously breathing the whole time. SOP for this type of procedure at my institution. (HINT: This wasn't in the OR. Think of this as a TIVA at a remote location.)

We're getting off track... Eggs? Propofol? Avoidance?

-copro

 

[jetproppilot]

Didn't intubate. Masked the kid, put in the IV, then maintained with another agent. Kid had no airway and was spontaneously breathing the whole time. SOP for this type of procedure at my institution. (HINT: This wasn't in the OR. Think of this as a TIVA at a remote location.)

We're getting off track... Eggs? Propofol? Avoidance?

-copro

Makes sense now.

 

[amyl]

go ahead and use propofol... its egg lechithin in propofol and people are allergic to another egg protein, not lechithin. i cannot remember the exact name of the other protein and am too lazy to look it up (after all i am a 4th year med student ;-). i think i read it in morgan/mikhail (again too lazy to look up the reference ;-). if i motivate to find my book amongst the packing boxes today i'll find the reference.

 

[coprolalia]

That's exactly right, Amy.

My rationale was right, but my explanation was wrong. I convinced this attending that it was okay to use propofol. We did. And, the kid did just fine. What was more worrisome to me was that this attending wanted to avoid propofol altogether simply for the fact that the kid had an egg allergy and that propofol contains eggs. We looked it up, and we both learned something. Win-win after an argument (of course, I'm the one who's going to get a bad eval for the day... f uck it.)

-copro

 

[Planktonmd]

go ahead an use propofol... its egg lechithin in propofol and people are allergic to another egg protein, not lechithin. i cannot remember the exact name of the other protein and am too lazy to look it up (after all i am a 4th year med student ;-). i think i read it in morgan/mikhail (again too lazy to look up the reference ;-). if i motivate to find my book amongst the packing boxes today i'll find the reference.

You are right and egg allergy is usually to egg Albumin so it's probably safe to give Propofol to people who have egg allergy.
But since there is no official agreement on this and since the manufacturer still lists egg allergy warning, the decision about using Propofol in patients with drug allergy should be done on a case by case basis and I would still avoid it in people with severe egg allergy.

 

[coprolalia]

... since the manufacturer still lists egg allergy warning...

I could not find such a warning in any of the current package inserts.

-copro

 

[Planktonmd]

I could not find such a warning in any of the current package inserts.

-copro

You are right!
Astra Zeneca used to mention "allergy to egg lecithin" but now it only says "allergy to any of it's components".
Whatever that means.
But it's definitely a less powerful statement.

 

[2ndyear]

http://www.anaesthesia-az.com/article/510664.aspx
14. Q: Can Diprivan be given to patients with an egg allergy since the formulation of "Diprivan" contains 1.2% egg yolk phospholipid?

A: The soybean oil which Zeneca uses in 'Diprivan' undergoes a stringent purification process whereby all protein within the oil is removed. Patients who are allergic to eggs are generally allergic to egg protein or albumin, not lecithin (the egg phosphatides which are present in the ‘Diprivan’ emulsion). A thorough search of the literature has revealed no evidence that lecithin is allergenic, or that it could act as a hapten, thus inducing allergenicity. The literature indicates that it is the glycoproteins found in food that are generally implicated as the allergenic component (Sampson and Cook, 1990).

The glycoproteins are characteristically water soluble, largely heat resistant and acid-stable, and commonly in the molecular weight range14-60 KDa. Sampson and Cook (1990) refer to four other papers where the specific allergenic components of egg and cow's milk have been isolated and characterised. They concluded that patients clinically allergic to egg and / or cows milk possess IgE and IgG antibodies to protein fractions in egg and cow's milk.

There is a recent case report by Bassett et. al. (1994) of an adverse allergic reaction to propofol in a patient with egg hypersensitivity. The authors state that 'propofol emulsion contains egg lecithin, a phosphatidylcholine found in egg yolk' and suggest that 'a history of egg allergy may have to be considered prior to administration of propofol'. This conclusion seems at odds with the studies quoted above. It seems more likely that the allergy in this case is due to either propofol or Intralipid, even though the incidence of allergy to either agent is very low. The incidence for propofol has been estimated to be 1 in 15 000 anaesthetics, irrespective of the mechanism involved and in 1 in 45 000 for immune reactions (Laxenaire et. al., 1992). The incidence with Intralipid is probably even lower. There have been very occasional reports of hypersensitivity following Intralipid eg., Kamath et.al., (1981) and Hiyama et. al. (1989). Hiyama et. al. (1989) using the RAST test demonstrated that an allergic response observed after Intralipid was probably due to soybean protein.

In conclusion, it does seem very likely that people who are allergic to eggs are allergic to the protein component. This could explain why 'Diprivan' is only very rarely a problem since the egg component in the emulsion is phospholipid. However, it is always advisable to ascertain the exact allergen in each individual case before deciding causality.

Also, more than once I've had patients tell me they're allergic to eggs only to find out that the effect is getting the runs.

 

[coprolalia]

Bottom line is that if your attending tells you that you have to avoid propofol because your patient has an egg allergy, feel free to call them an idiot.

-copro

 

[VentdependenT]

Egg allergy is not a contraidication to Propofol.

A quick internet search will reveal that.

If there is a reaction its most likely an anaphalacTOID one. TTX is the same. Epi, Fluids, D/C offending agent, 100%o2, benadryl, corticosteroids, pepcid.

Remember that Diprivan has EDTA (that nasty preservative which causes back spasms in the old chorprocaine) in it. Possible that patients with sensitivity to that may have a reaction.

 

[nociceptor]

maybe this will help

[FONT=Arial, Helvetica, sans-serif][FONT=Arial, Helvetica, sans-serif][SIZE=+1]Possible Anaphylaxis after Propofol in a Child with Food Allergy
Hofer et al. Ann Pharmacother.2003; 37: 398-401 [/SIZE]..

OBJECTIVE: To report a case of anaphylaxis due to propofol in a child with allergies to egg and peanut oil. CASE SUMMARY: A 14-month-old boy with a history of reactive airway disease was hospitalized for treatment of respiratory symptoms. The patient had documented allergies to egg, peanut oil, and mold. Within the first few hours after admission, acute respiratory decompensation occurred, and arrangements were made to transfer the patient to our tertiary-care hospital. Prior to transfer, he was emergently intubated under sedation and paralysis with propofol and rocuronium. When emergency air transport arrived, the patient was hypotensive and tachycardic. His symptoms of anaphylaxis were managed throughout the flight and, upon arrival at our institution, the patient was admitted to the Pediatric Intensive Care Unit. He improved over a 5-day hospital course, and his caregivers were instructed to avoid propofol in the future. The patient's anaphylactic reaction following propofol was rated as a possible adverse drug reaction using the Naranjo probability scale. DISCUSSION: The use of propofol in pediatric patients for procedural sedation has gained increased favor. Since the propofol formulation contains both egg lecithin and soybean oil, its use is contraindicated in patients with hypersensitivities to these components. Several other drugs have a food component, resulting in contraindications and warnings in product labeling. CONCLUSIONS: Propofol should be avoided in patients with allergies to egg and/or soybean oil, if possible. Clinicians should consider the potential for adverse drug events in patients with select food allergies.

 

[Frank Rizzo]

why risk it? use something else.

 

[coprolalia]

Nociceptor: N=1. And, in the discussion that ensued from that case report, many responses were quick to point out that they did not rule out other possibilities of this patient's presentation. In other words, they never proved that the propofol was the source of the reaction, let alone the egg lecithin in it.

Rizzo: Because every anesthetic has risks, and sometimes you have to weigh which has a greater risk/benefit ratio to the patient. In this case, the alternate plan (ketamine and precedex) were not only more costly, but also more risky to this patient. What kills babies, after all? Bradycardia. Are you so sure that this kid is going to tolerate that anesthetic better? What about airway manipulation and gas? What if this kid had MH as a result, which is far more likely to happen than a reaction to egg lecithin?

Furthermore, if you understand what causes the allergy, and you understand the physiology and pharmacology, then you would realize that unless the patient has a specific anaphylactic allergy to egg lecithin (which would be extraordinarily unusual), then you can safely proceed. This is so clear to the manufacturers and the FDA that the do not even require "egg allergy" as a contraindication in the package insert. If the mom had said, "My baby had eggs and almost died," then I might have agreed and considered an alternate plan. Even then, I probably still would've used propofol because the allergy is to protein in eggs, not the fat. And, if this kid would've had a reaction to the egg lecithin - and I could've subsequently proved it - I probably would have had the very first actual case report of this happening.

You can choose to be a thinking scientist and a clinician, or you can be an uninformed robot. Your choice.

-copro

 

[coprolalia]

And, another thing...

Propofol should be avoided in patients with allergies to egg and/or soybean oil, if possible.

Who the hell are they, with their single case report, to make such a recommendation? They admit that it was only a "possible" cause, in that they didn't even make the effort to rule out other possible causes, and yet they tag this case report with this bullsh*t in the conclusion. What about MH? Should we avoid all inhalational agents in children receiving their first anesthetic simply because there is a risk of MH? Which is a more serious complication, an anaphylactoid reaction or MH?

It's fine to make a case report, but nothing pisses me off more than sloppy science making generalizations based on limited and incomplete data. The people who published this are *****s. Who published this? I bet it was a bunch of PICU doctors.

I got a newsflash, folks. Propofol is used safely in thousands of kids everyday, even those with food allergies. Risk/benefit. Consider what other risks you're putting your patient at when you consider your "alternate" plan to avoid a non-issue.

-copro

 

[coprolalia]

Nevermind... I shoulda known... pharmacists! (Sorry PICU docs... I still hate you, though. 😍 )

What about the rocuronium? And, the kid was already sick to begin with. Cheezus. I can't believe that this "case report" actually got published.

-copro

 

[nociceptor]

Corpo

Nope, if one random journal says it is one way based on one person you had better follow it! The law is the law!😱😱

 

[coprolalia]

Corpo

Nope, if one random journal says it is one way based on one person you had better follow it! The law is the law!😱😱

Yeah, dude, well you better believe the lawyers are going to pull this study out if you ever get sued... Irresponsible publishing in an unimportant journal. Doesn't "peer review" mean anything anymore?

-copro

 

[nociceptor]

Yeah, dude, well you better believe the lawyers are going to pull this study out if you ever get sued... Irresponsible publishing in an unimportant journal. Doesn't "peer review" mean anything anymore?

-copro

I would laugh if your attending subscribes to this journal.

never miss an issue🙄

 

[tussionex]

Nevermind... I shoulda known... pharmacists! (Sorry PICU docs... I still hate you, though. 😍 )

What about the rocuronium? And, the kid was already sick to begin with. Cheezus. I can't believe that this "case report" actually got published.

-copro

hey, this pharmacist happens to think that painting propofol with such a broad brush based on ONE case with an ALREADY sick kid is horse$hit!
i'm with you....risk vs benefit!

 

[coprolalia]

hey, this pharmacist happens to think that painting propofol with such a broad brush based on ONE case with an ALREADY sick kid is horse$hit!
i'm with you....risk vs benefit!

It's all good, tussionex. It's just one of my personal "issues" rearing its ugly head... namely the tendencies of a couple of PharmD's I know who wrongfully think they actually have an MD behind their name. When they round with us in the ICU, their "suggestions" sometimes border on treatment decisions. Clearly, they usually have numerous studies and theory backing their opinions, and often their input is valid and appreciated. But, other times they don't necessarily jibe with actual clinical practice or the immediate needs of whichever patient upon whom they may be commenting, and they can be downright persistent and stubborn in trying to make their case.

One time, this particular PharmD insisted that I give a patient steroids before she got contrast dye to prevent an anaphylactic reaction that had never happened to her before... sheesh! She even tried to go over my head after I said "no, that's not good clinical decision making". Of course, after ignoring me my attending also subsequently looked at her like she was from Mars when she suggested it to him. Pissed me off at the time, but now I can see that she just made herself look like a *****. Problem is, I don't think she realized that she looked like a *****.

-copro

 

[PharmD2MD]

It's all good, tussionex. It's just one of my personal "issues" rearing its ugly head... namely the tendencies of a couple of PharmD's I know who wrongfully think they actually have an MD behind their name. When they round with us in the ICU, their "suggestions" sometimes border on treatment decisions. Clearly, they usually have numerous studies and theory backing their opinions, and often their input is valid and appreciated. But, other times they don't necessarily jibe with actual clinical practice or the immediate needs of whichever patient upon whom they may be commenting, and they can be downright persistent and stubborn in trying to make their case.

One time, this particular PharmD insisted that I give a patient steroids before she got contrast dye to prevent an anaphylactic reaction that had never happened to her before... sheesh! She even tried to go over my head after I said "no, that's not good clinical decision making". Of course, after ignoring me my attending also subsequently looked at her like she was from Mars when she suggested it to him. Pissed me off at the time, but now I can see that she just made herself look like a *****. Problem is, I don't think she realized that she looked like a *****.

-copro

I think a lot of the problem has to do with some PharmD's having a partial understanding of the issue at hand, or they just have a really narrow viewpoint. Another issue is that clinical pharmacists are still trying to figure out what exactly their role is- it's a somewhat new niche, and there are some growing pains, and they put their foot in their mouth occasionally.

I don't post here much, but I like reading about your pharmacological conundrums. I'm sort of thinking about anesthesia, but I'm just finishing up 2nd year now, so I still have a long ways to go. Thanks.

 

[tussionex]

When they round with us in the ICU, their "suggestions" sometimes border on treatment decisions. Clearly, they usually have numerous studies and theory backing their opinions, and often their input is valid and appreciated. But, other times they don't necessarily jibe with actual clinical practice or the immediate needs of whichever patient upon whom they may be commenting, and they can be downright persistent and stubborn in trying to make their case.

therein lies the problem. people like that give people like me a bad name. it's nice to be a "clinical pharmacist" but there's more to it than being able to read a journal article. too many off my peers seem to be literature/guideline bound and don't take the whole picture and a healthy dose of common sense into account.

send your steroid-happy pharmD to me...i'll beat it out of her. 😀

 

[coprolalia]

send your steroid-happy pharmD to me...i'll beat it out of her. 😀

I'd love to. She's so friggin' arrogant. One of the pharm residents I hung out with last year (who was a bona fide hottie, but moved away at the end of her year 🙁 ) was under her tutelage. When I first got to know the hottie, I mistakenly thought that she was just like the steroid-pusher. As I got to know her, I found out she was much more reasonable and circumspect. At the end of the year, I was quite shocked that even she was embarassed on rounds with this particular PharmD's attitude and actions. She called her her least favorite preceptor during the entire year.

I try not to lump people together, but the system is built that way. I'm continually amazed at how services that overlap can have such a different perception of reality and the best course of action for a particular patient, depending on how they've been trained. It is for this very reason that I especially hate the PICU intensivists... 😍

-copro

 

[tussionex]

I'd love to. She's so friggin' arrogant. One of the pharm residents I hung out with last year (who was a bona fide hottie, but moved away at the end of her year 🙁 ) was under her tutelage. When I first got to know the hottie, I mistakenly thought that she was just like the steroid-pusher. As I got to know her, I found out she was much more reasonable and circumspect. At the end of the year, I was quite shocked that even she was embarassed on rounds with this particular PharmD's attitude and actions. She called her her least favorite preceptor during the entire year.

I try not to lump people together, but the system is built that way. I'm continually amazed at how services that overlap can have such a different perception of reality and the best course of action for a particular patient, depending on how they've been trained. It is for this very reason that I especially hate the PICU intensivists... 😍

-copro

i try to incorporate logic, common sense, and some sense of teamwork into my day to day in-hospital actions. and i try to reinforce that with our students.

however, if you want to make sweeping generalizations, lots of pharmacists, including this one, are bona fide hotties! 😉

 

[lkuh]

go ahead and use propofol...

Attorney: So, Dr. Amyl, your patient died of an anaphylactic reaction to propofol. Does the package insert specifically state that propofol should not be used in patients with allergies to eggs and egg products.

Dr. Amyl: Yes, it does.

Attorney: Would you like the money to come from your bank account or your insurance company?

 

[Neon Goat]

Attorney: So, Dr. Amyl, your patient died of an anaphylactic reaction to propofol. Does the package insert specifically state that propofol should not be used in patients with allergies to eggs and egg products.

Thanks lkuh, I've been waiting 3 years for someone to complete this thread 🙂

Seriously though, I did learn something about egg allergies and propofol. I'm curious, how did you decide here was going to be your first post? I'm assuming you were searching for eggs and propofol allergies.

 

[geogil]

Attorney: So, Dr. Amyl, your patient died of an anaphylactic reaction to propofol. Does the package insert specifically state that propofol should not be used in patients with allergies to eggs and egg products.

Dr. Amyl: Yes, it does.

Attorney: Would you like the money to come from your bank account or your insurance company?

wait, you did a search, came up with this 2008 thread, only to post that? And on your first post, to boot?

 

[imfrankie]

Attorney: So, Dr. Amyl, your patient died of an anaphylactic reaction to propofol. Does the package insert specifically state that propofol should not be used in patients with allergies to eggs and egg products.

Dr. Amyl: Yes, it does.

Attorney: Would you like the money to come from your bank account or your insurance company?

Mr. Attorney, you are stating the patient died of an anaphylactic reaction to propofol, are you a physician also?

 

[pgg]

Attorney: So, Dr. Amyl, your patient died of an anaphylactic reaction to propofol. Does the package insert specifically state that propofol should not be used in patients with allergies to eggs and egg products.

Dr. Amyl: Yes, it does.

Attorney: Would you like the money to come from your bank account or your insurance company?

Not all propofol is made with egg yolk.

How do we know the propofol is the culprit? The patient is also likely to have been given a bunch of other drugs at the same time, some of which are known to have higher rates of allergy such as NMBDs and antibiotics. Then there's the opiate, one or more antiemetics, midazolam, maybe some lidocaine. Maybe it was a warm spring day, the window was open, and a bee flew into the OR.


To take this a step further, there are black box warnings on lots of drugs we use, and any greasy POS lawyer would certainly froth at a complication he could somehow tie to that warning ... that doesn't mean sane anesthesiologists won't use those drugs.

I used propofol in an egg allergy patient just a couple days ago.


Last anaphylaxis case I witnessed, we never identified the agent. It just happened out of nowhere, classic anaphylaxis, but no drug had recently been given.


Liability is part of what we do. I'm not going to start sweating egg allergies.

 

[proman]

Last anaphylaxis case I witnessed, we never identified the agent. It just happened out of nowhere, classic anaphylaxis, but no drug had recently been given.

What was the case? Any chance the surgeons were wearing latex gloves? A friend of mind was doing a peds spine case, pt got a little hypotensive, gave some hetastarch, got more hypotensive, more hetastarch, coded, epi, ROSC. Very rare but some things we don't recognize as drugs are allergens.

 

[Idiopathic]

What was the case? Any chance the surgeons were wearing latex gloves? A friend of mind was doing a peds spine case, pt got a little hypotensive, gave some hetastarch, got more hypotensive, more hetastarch, coded, epi, ROSC. Very rare but some things we don't recognize as drugs are allergens.

have certainly seen anaphylaxis with this and it is well reported, i believe

 

[pgg]

What was the case? Any chance the surgeons were wearing latex gloves? A friend of mind was doing a peds spine case, pt got a little hypotensive, gave some hetastarch, got more hypotensive, more hetastarch, coded, epi, ROSC. Very rare but some things we don't recognize as drugs are allergens.

Ortho case, some ankle thing. It actually hit in the PACU about 5 minutes after arriving. No latex anything there. No drugs were given.

Last drug was some Toradol about 15 min prior to leaving the OR. We thought maybe it was given into a closed IV line, and the PACU nurse opened the IV and it actually hit the patient in the PACU, but that's kind of a stretch.

Classic presentation. Abrupt, wheezing, bronchospasm, desaturation, rash and skin wheals all over his chest and arms and face, hypotension to the 60s systolic. Epi made it all better.

I don't know, maybe there was a bee in the room.

 

[proman]

I don't know, maybe there was a bee in the room.

We only have flies. Patient safety etc.

 

[RussianJoo]

I hate posting on old dead threads.. but this one was resurrected i'll post. the ASA newsletter from February of this year had an Anesthesiology Continuing Education question. " A patient with a history of egg allergy recieves a standard induction dose of generic propofol. Which of the following side effects is MOST likely to occur? "

the answer was Bronchospasm. the resason it wasn't anaphylaxis is because " most egg allregies are due to egg albumin not egg phosphatide which is what is used in propofol."

sorry if this was posted before in 2008.

 

[foxtrot]

why risk it? use something else.

What sucks is that for off site anesthesia/sedation, what else do you use for a pedi patient if you don't have access to an inhalational agent? STP is gone. I guess you would have to use Ketamine and just keep the kid a while longer in the recovery area. We are running out of induction agents. STP was a great drug in the right population, particularly peds since it didn't burn the same way propofol does.

 

[sevoflurane]

I don't know, maybe there was a bee in the room.

🤣🤣

 

[IlDestriero]

What sucks is that for off site anesthesia/sedation, what else do you use for a pedi patient if you don't have access to an inhalational agent? STP is gone. I guess you would have to use Ketamine and just keep the kid a while longer in the recovery area. We are running out of induction agents. STP was a great drug in the right population, particularly peds since it didn't burn the same way propofol does.

Everywhere we go off site we have an anesthesia machine there. Onco, rads, IR, MRI, GI, etc.
Though, I still miss STP!!!🙁
What are people using for burst suppression these days?

 

[ssmallz]

What are people using for burst suppression these days?

Propofol