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summary
1
• β-lactam allergy, particularly penicillin allergy is the most common perioperative patient-reported sensitivity, in up to 35% of patients.
• Unneccessary switching to non-β-lactams for surgical prophylaxis is not cost-free, and is contributing to the rise of c. difficile and vancomycin-resistant Enterococcus (VRE).

• Patient history of penicillin allergy is of variable quality, and often does not allow the allergy to be ruled-out.

• Step 1 – differentiate drug side effects from allergy. Isolated nausea, vomiting or diarrhoea are usually side effects.

• Step 2 – identify the type of hypersensitivity.

  • Most drug reactions are Type 4 (T-cell mediated), delayed from 2 hours to days after exposure. Mostly benign cutaneous symptoms (eg. rash) that do not necessarily require avoiding future β-lactam exposure, except in the case of Stevens-Johnson syndrome.
  • Type 1 (IgE-mediated) hypersensitivities are immediate (minutes to 2 hours) but less common, causing urticaria, angioedema and/or anaphylaxis. Future exposure should be avoided.
  • Type 2 (cytotoxic) and Type 3 (immune complex) are much less common, and present with more serious, though delayed, reactions (days to weeks).

• Take home: Mild symptoms (eg. rash developing more than 2h after exposure) probably do not require β-lactam avoidance. If there is a history of moderate or severe reaction, then avoiding all β-lactams is wise.

• Of interest: Although R1 side-chain similarity is the main contributor to penicillin-cephalosporin cross-reactivity, importantly, 1st generation cephazolin has a different R1 side-chain and has been reported to not cross-react. Other cephalosporins share side-chains with specific penicillins.

• Finally, stop giving IV test doses. It makes no sense from a safety point of view and offers no useful information.
Hermanides J, Lemkes BA, Prins JM et al. Presumed β-Lactam Allergy and Cross-reactivity in the Operating Theater: A Practical Approach. Anesthesiology. 2018 Aug 1; 129 (2): 335-342.
  Daniel Jolley
comment
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BIS may not correlate well with isolated forearm monitoring of adequacy of depth of general anesthesia for cesarean section.
Zand F, Hadavi SM, Chohedri A et al. Survey on the adequacy of depth of anaesthesia with bispectral index and isolated forearm technique in elective Caesarean section under general anaesthesia with sevoflurane. Br J Anaesth. 2014 May 1;112(5):871-8.
  Daniel Jolley
pearl
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Epidural fentanyl does not have an effect on breastfeeding initiation.
Wilson MJ, MacArthur C, Cooper GM et al. Epidural analgesia and breastfeeding: a randomised controlled trial of epidural techniques with and without fentanyl and a non-epidural comparison group. Anaesthesia. 2010 Feb 1;65(2):145-53.
  Daniel Jolley
pearl
1
Routine preoperative echocardiography before operative repair of hip fracture does not reduce mortality or postoperative complcayions.
Yonekura H, Ide K, Onishi Y et al. Preoperative Echocardiography for Patients With Hip Fractures Undergoing Surgery: A Retrospective Cohort Study Using a Nationwide Database. Anesth. Analg. 2019 Feb 1; 128 (2): 213-220.
  Daniel Jolley
pearl
1
Perioperative clonidine administration does not reduce mortality or myocardial infraction, but does increase the risk of hypotension and non-fatal cardiac arrest.
Devereaux PJ, Sessler DI, Leslie K et al. Clonidine in patients undergoing noncardiac surgery. N. Engl. J. Med. 2014 Apr 17; 370 (16): 150415131504-13.
  Daniel Jolley
pearl
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Ondansetron, dexamethasone, droperidol and total intravenous anesthesia (TIVA) all have a roughly similar, productive effect to reduce postoperative nausea and vomiting (PONV) by about one third.
Apfel CC, Korttila K, Abdalla M et al. A factorial trial of six interventions for the prevention of postoperative nausea and vomiting. N. Engl. J. Med. 2004 Jun 10; 350 (24): 244124512441-51.
  Daniel Jolley
pearl
1
BIS monitoring may not reduce the incidence of awareness under general anesthesia.
Avidan MS, Zhang L, Burnside BA et al. Anesthesia awareness and the bispectral index. N. Engl. J. Med. 2008 Mar 13;358(11):1097-108.
  Daniel Jolley
pearl
1
The incidence of awareness-with-recall under general anesthesia in the United States is 1-2 cases per 1,000 patients.
Sebel PS, Bowdle TA, Ghoneim MM et al. The incidence of awareness during anesthesia: a multicenter United States study. Anesth. Analg. 2004 Sep 1;99(3):833-9, table of contents.
  Daniel Jolley
comment
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Note that the reported ’reduction in respiratory failure’ was entirely due to a small difference in post-op ventilation duration in the ICU between the groups. Significant, but perhaps not clinically remarkable.
Rigg JR, Jamrozik K, Myles PS et al. Epidural anaesthesia and analgesia and outcome of major surgery: a randomised trial. Lancet. 2002 Apr 13; 359 (9314): 127612821276-82.
  Daniel Jolley
pearl
1
Perioperative epidural analgesia in high-risk patients undergoing major abdominal surgery improves analgesia but does not have other morbidity or mortality benefits.
Rigg JR, Jamrozik K, Myles PS et al. Epidural anaesthesia and analgesia and outcome of major surgery: a randomised trial. Lancet. 2002 Apr 13; 359 (9314): 127612821276-82.
  Daniel Jolley