A 45 year-old female presents for unilateral, radical mastectomy. The patient has a history of malignant hyperthermia, is allergic to egg yolks, refuses etomidate due to nausea with prior uses, fears bad dreams from ketamine, worries about drug interactions with thiopental, dislikes the forgetfulness of benzodiazepines, and fears addiction from opioids. The patient is also intensely claustrophobic. She requests a regional anesthetic for her surgery, and complete avoidance of sedation or general anesthesia.
Questions for consideration:
1. Is propofol contraindicated based upon her allergy?
2. How would you counsel this patient on the risks, benefits and alternatives of her request?
3. For a complete regional anesthetic, which nerves would need to be blocked? Which nerve blocks would you employ?
Related posts:
1. There is no straightforward answer to propofol and egg allergy. People allergic to eggs are most likely allergic to the protein component and Diprivan is highly purified so it is probably ok. The literature is below. However in this patient who has this particular complicated history, I think any clinician would “play it safe” and not sedate with propofol.
Bassett,C.W., Talusan-Canlas,E., Holtzin,L., Kumar,S., Chiaramonte,L.T.
An adverse reaction to propofol in a patient with egg hypersensitivity
Journal of Allergy and Clinical Immunology, 1994* 93 (1) Part 2: 242 Abs 476
Hiyama,D.T., Griggs,B., Mittman,R.J., et. al.
Hypersensitivity following lipid emulsion infusion in an adult patient
Journal of Parenteral and Enteral Nutrition, 1989, 13 (3) 318 – 320
Kamath,K.R., Berry,A.
Acute hypersensitivity reaction to Intralipid
New Engalnd Journal of Medicine, 1981, Feb 5* 360
Laxenaire,M.C., Maten-Bermejo,E., Moneret-Vautrin,D.A., Gueant,J.L.
Life-threatening anaphylactoid reactions to propofol (’Diprivan’)
Anesthesiology, 1992, 77: 275 – 280
Sampson,H., Cook,S.K.
Food allergy and the potential allergenicity-antigenicity of microparticulated egg and cow’s milk proteins
Journal of the Amercian College of Nutrition, 1990* 9 (4)* 410 – 417
2. I would refer her to Dr Tighe!! What a nightmare history. If she is clausterphobic she will not do well awake. She did not mention having an adversity to nitrous. You could do straight regional with nitrous and O2 and I think she would need to accept benzos if she could not tolerate the procedure. Ofcourse conversion to GA is always the gold standard back up plan and having a high thoracic block may bother her a lot. Avoiding triggers of MH and taking seriously her egg allergy would involve opioid based anesthesia and then we get into the discussion of opioids and immunosuppression with breast cancer. I think that I would delay her case and seek an allergist opinion about propofol (have her tested?) and then use a propofol based anesthetic if GA or sedation was needed.