Perioperative considerations for the food‐allergic pediatric patient

Patients with a history of food allergy and food intolerance are common in the pediatric population and are encountered frequently in the perioperative setting by pediatric anesthesiologists. Perioperatively, food allergy can present on a spectrum ranging from minor acute urticaria to more severe hypovolemia and anaphylactic shock. Allergy to foods including fruits, fish, egg, soy, and peanut are most concerning for their potential to cross‐react with perioperative medications. There is little in the anesthesia literature that focuses on the perioperative management of children with food allergies. This educational review will provide a brief overview of classic immunoglobulin E (IgE)‐mediated food allergies, less common non‐IgE food allergies, and present perioperative considerations for these patients. An audio summary of this topic is included as Supplementary Audio S1 .     

Immunoglobulin E-mediated food allergies among adults with allergic rhinitis

Objective

To compare the prevalence of food allergy for peanut, shrimp, and milk in adults with allergic rhinitis and to determine predictive values of these allergens and total immunoglobulin E (IgE) to detect food allergies.

Study Design

Cross-sectional study.

Setting

University of Chicago Medical Center, Chicago, Illinois.

Subjects and Methods

We retrospectively analyzed in vitro enzyme-linked immunosorbent assays of adults with rhinitis. Subjects were tested for nine inhalants and three foods (peanut, shrimp, milk) and total IgE. Subjects with food allergy history were tested with additional foods. The sensitivity (SE), specificity (SP), positive predictive value (PPV), and negative predictive value (NPV) of the allergens and total IgE to detect food allergies were calculated.

Results

A total of 283 subjects received in vitro tests. Forty-one percent tested negative and 59 percent tested positive for inhalants. The prevalence of subjects with a positive peanut or shrimp allergy in the inhalant-positive population was significantly greater than subjects with milk allergy (23.4% peanut [P = 0.008], 22.2% shrimp [P = 0.001], and 13.2% milk [P = 0.008], P = 0.001). For subjects with food allergy history, peanut had the best SP (100.0%), SE (28.1%), PPV (100.0%), and NPV (64.6%) in detecting allergies to other foods. In patients positive for the initial panel (inhalants and peanut), the SP, SE, PPV, and NPV of elevated total IgE was 71.4, 72.4, 77.8, and 65.2 percent, respectively.

Conclusion

Peanut and shrimp were the most common foods encountered in adults with allergic rhinitis. Peanut was best in predicting other food allergies. Total IgE levels with inhalants plus peanut provided the optimal combination of SE, SP, PPV, and NPV. In vitro testing may be important to identify and prevent anaphylaxis to foods in adults.     

Influence of sensitization to inhalative allergens on adenotonsillar disease.

OBJECTIVE: We sought to determine the influence of IgE-mediated sensitization on adenotonsillar disease in children. We compared follow-up after tonsillectomy/adenoidectomy of atopic and nonatopic children.Study design and setting A prospective study of 293 children consecutively undergoing tonsillectomy/adenoidectomy was conducted at a university hospital center. Preoperative and postoperative (1-year follow-up) allergy-related symptom scores were obtained by parents. Intraoperative total serum IgE, the screening test sx1 (Pharmacia), and, if positive, serum specific IgE to inhalative allergens were carried out. RESULTS: Sixty-seven children (22.9%) showed positive RAST results to inhalative allergens (class 1 to 6). In both sensitized and nonsensitized groups, the general health was improved in more than 89% at 1 year postoperatively. No significant difference of postoperative nasal symptoms between the atopic and nonatopic groups was found. CONCLUSION: Both atopic and nonatopic children with adenotonsillar disease improve health after adenoidectomy or adenotonsillectomy. In our opinion, routine allergy tests before adenotonsillectomy or adenoidectomy are not justified. Only if allergy is suspected due to clinical findings or family history should an allergy test be carried out.     

Propofol use in children with allergies to egg,peanut, soybean or other legumes

Propofol is the most commonly administered intravenous agent for anaesthesia in children. However, there are concerns that the emulsified preparation may not be safe in children with an allergy to egg, peanut, soybean or other legumes. We conducted a retrospective study of children with immunologically confirmed egg, peanut, soybean or legume allergy and who underwent general anaesthesia at Princess Margaret Hospital for Children between 2005 and 2015. We extracted details regarding allergy diagnosis, each anaesthetic 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 our prospective anaesthesia research database and acted as a control group. We identified 304 food-allergic children and 649 procedures where propofol was administered. Of these, 201 (66%) had an egg allergy, 226 (74%) had a peanut allergy, 28 (9%) had a soybean allergy and 12 (4%) had a legume allergy. These were compared with 892 allergy-free patients who were exposed to propofol. 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 child with a previous history of intralipid allergy. We conclude that genuine serious allergic reaction to propofol is rare and is not reliably predicted by a history of food allergy.     

Transfer of peanut allergy following lung transplantation: a case report

This case study describes a patient who developed peanut allergy following lung transplantation. A 54-year-old woman underwent bilateral lung transplantation on June 2009 owing to severe chronic obstructive pulmonary disease. She had no history of food allergy before transplantation. The donor, however, was a 20-year-old man who was fatally injured during an automobile accident; he was allergic to peanuts. At 3 months after transplantation, the lung recipient presented with acute dyspnea and urticaria 15 minutes after consuming food containing peanut derivatives. Pre- and posttransplantation recipient blood samples analyzed for the presence of IgE antibodies specific for peanut allergens confirmed that the allergy had been passively transfered as a consequence of transplantation. Food allergy following solid organ transplantation is thought to be rare, mostly occurring in children. Two mechanisms may explain the observations described for the patient reported in this study: de novo development of peanut allergies after transplantation, or passive transfer of peanut allergies from a peanut-sensitized organ donor. This case report documenting pre- and posttransplantation IgE status in a lung transplantation case suggested that the allergic status of organ donors should be thoroughly assessed before transplantation, and potential allergy transfer risks must be discussed with the transplant team and the patient.     

Allergic comorbidities in bronchial asthma, in children

Bronchial asthma is the most frequent chronic disease of childhood. The association of this disease with allergic rhinitis increases the prevalence and severity of bronchial asthma to 60% compared with 2% in subjects without allergic rhinitis. Food allergy can be expressed in a variety of respiratory symptoms, especially when IgE mediated immune responses are involved. In children, the prevalence of bronchial asthma associated with food induced atopic eczema is 2-8% and respiratory clinical picture can be a component of the multisystem anaphylactic reaction or of chronic respiratory disease like bronchial asthma, serous otitis. The association of other allergic comorbidities, like sinusitis, ocular allergies, lymphoid hypertrophy, sleep obstructive apnoea, leads to the conclusion that allergic bronchial asthma (extrinsic) is a systemic disease, with onset at any age, and the dominant clinical feature depends on the child's genetic pattern.     

The role of IgE-mediated hypersensitivity in otitis media with effusion

Forty-one children with recurrent otitis media with effusion (OME) were evaluated for IgE mediated allergy by critical analysis of history, physical findings, skin testing for selected antigens, and laboratory determination of total IgE and radioallergosorbent testing (RAST) for six inhalant and two food allergens. The children were divided into an allergic and nonallergic group. The allergic group clearly had higher total IgE in their serum. There was an elevation of middle ear effusion (MEE) IgE in 5 of 20 allergic cases. In three of these five patients or 15% of the allergic group, the IgE/mg protein was higher in the MEE than in the corresponding serum, suggesting the possibility of local production of IgE. Specific IgE antibody as measured by RAST was noted in 9 of 20 MEE and 5 of 20 nasal washings in the allergic group and in only 2 of 21 MEE and in 10 nasal washings of the nonallergic group. Nasal IgE was substantially increased in three patients of the allergic group; however, the corresponding MEE IgE was not increased in proportion to the nasal IgE. The MEE RAST was positive in 22% of the allergic group and in less than 1% of the nonallergic group. Nasal RAST was positive in 20% of the allergic group and in none of the nonallergic group. We conclude that IgE-mediated allergic reactions may play a role in the pathogenesis of OME in only about 15% of children defined as allergic on the basis of clinical and laboratory evidence. Allergy investigation as a diagnostic procedure in children with recurrent OME, but without a history of allergy on the basis of history, family history, or laboratory testing is likely to be nonproductive.     

Prevalence of heat shock protein in patients with Meniere''s disease and allergy

OBJECTIVE: The study purpose was to investigate the prevalence of elevated heat shock protein 70 (HSP-70) in patients with Meniere's disease who have milk allergy compared with those who are not allergic to milk. METHODS: Fifty-five patients with Meniere's disease and allergy in whom milk allergy had been confirmed by intradermal progressive dilutional food testing or skin testing to milk antigen were included. Blood serum was tested for HSP-70 elevation with a Western blot assay using bovine renal extract. The 29 women and 26 men ranged in age from 29 to 76 years (mean age 52.8 years). Forty percent of the patients had bilateral Meniere's disease. RESULTS: Overall prevalence of HSP-70 elevation was 29.1%. This was higher in bilateral patients (50%) than unilateral patients (15%) (P 相似文献   

Propofoleinsatz für Hals-Nasen-Ohren-Eingriffe im Kindesalter

BACKGROUND: The aim of this study was an improvement in patient comfort, reduction of anaesthesia costs and room contamination by the use of propofol for adenoidectomy. METHODS: A total of 103 infants (aged 1-5 years) undergoing elective adenoidectomy were randomized for anaesthesia with sevoflurane-nitrous oxide/oxygen (group 1), sevoflurane-air/alfentanil (group 2), alfentanil-propofol under induction with sevoflurane (group 3) or alfentanil-propofol (group 4). RESULTS: Using propofol, postoperative agitation and emesis were significantly less and the anaesthesia costs as well as the need for analgesics was reduced compared to inhalative anaesthesia. CONCLUSIONS: The use of propofol for preschool children undergoing ear, nose and throat (ENT) surgery seems to be advantageous because of less postoperative agitation, emesis and costs.     

Postoperative pain, nausea and vomiting following paediatric day-case tonsillectomy

More than 30% of all surgical activity for children in England and Wales is accounted for by routine ENT operations. There is known to be a high incidence of postoperative pain, nausea and vomiting following paediatric tonsillectomy with or without adenoidectomy. This prospective study examined the incidence of these complications in 100 children admitted for routine, elective day-case tonsillectomy, with or without adenoidectomy. The children were anaesthetised in accordance with our standard paediatric day-case protocol. The incidence of vomiting on the day of surgery was significantly less in the group anaesthetised in accordance with the protocol, compared to those in previously published studies. Postoperative pain was well controlled, with 88% of the children having minimal pain on the day of surgery, and reporting a pain score of 0-2. Modifying the anaesthetic care to a protocol designed to reduce postoperative pain, nausea and vomiting achieved measurable improvements in the recovery of this group following surgery. It has enabled us to evolve from a 100% inpatient stay for these operations to 98% day-case discharge rate, with minimal post anaesthetic or surgical morbidity. We describe the protocol and discuss the implications of implementing such a protocol for children undergoing these common operations.     

Incidence and risk factors of perioperative respiratory adverse events in children undergoing elective surgery

BACKGROUND: Adverse respiratory events remain one of the major causes of morbidity during anaesthesia, especially in children. The purpose of this prospective study was to determine the incidence of perioperative respiratory adverse events (PRAE) during elective paediatric surgery and to identify the risk factors for these events. METHODS: Potential risk factors (atopy, eczema, rhinitis, food allergy, previous allergic tests, pollens or animal allergy, passive smoking, obstructive sleep disorders) were assessed using the International Society on Allergy and Asthma (ISAAC) questionnaire, which was submitted to the parents during preoperative anaesthetic assessment. Anaesthetic and surgical conditions were systematically recorded. A multivariate logistic regression explaining PRAE was developed in 800 children. RESULTS: The intraoperative incidence of respiratory adverse events was 21% and the incidence in the postanesthetic care unit was 13%. According to the multivariate analysis, children not anaesthetized by a specialist paediatric anaesthesiologist have 1.7 increased risk to present PRAE (95% CI = 1.13-2.57). Children anaesthetized for ear, nose, throat (ENT) surgery had a 1.57-fold higher risk of PRAE compared with other procedures (95% CI = 1.01-2.44). Furthermore, there was a synergistic interaction when two risk factors: residents and ENT surgery, were concomitant: the odds ratio (OR) of PRAE during non-ENT surgical procedures was 1.43 (95% CI = 0.91-2.24), but increased to 2.74-fold (95% CI = 1.15-4.32) for ENT surgery. The risk of PRAE was significantly lower when the anaesthetic technique included tracheal intubation with relaxants (OR = 0.6, 95% CI = 0.45-0.95) and decreased by 8% with each increasing year of age. CONCLUSIONS: This study demonstrates a high incidence of PRAE in paediatric surgical patients without respiratory tract infections, which appears to be primarily determined by the age of the child and the anaesthetic care rather than by the child's medical history.     

Nocturnal enuresis and allergy

OBJECTIVE: To investigate whether an interaction exists between nocturnal enuresis and allergy. MATERIAL AND METHODS: Thirty-seven (20 boys, 17 girls) children with monosymptomatic nocturnal enuresis were recruited. We studied an allergy panel that included total IgE, 10 examples of inhalant-specific IgE, 10 examples of food-specific IgE, eosinophilic cationic protein (ECP) and Phadiotop. The same panel was studied in a control group of 18 children without monosymptomatic nocturnal enuresis. RESULTS: We did not determine statistically significant differences between the enuretic group and the control group in terms of levels of total IgE, the 10 examples of inhalant-specific IgE and Phadiotop. However, two (soybean and hazelnut) of the 10 food-specific IgE and ECP levels did differ significantly between the two groups. CONCLUSIONS: This first specific IgE study showed that there may be a relationship between nocturnal enuresis and soybean and hazelnut food allergens. Our findings may explain some cases of nocturnal enuresis. However, further studies are necessary to explain the underlying mechanisms and management of this disorder.     

Role of cross-allergies to latex in clinical routine of anesthesia

STUDY OBJECTIVE: To determine the applicability and reliability of a screening questionnaire to detect patients at high-risk of latex allergy; to assess the importance of other allergies such as profilin allergies (pollinosis) for presence of latex sensitization; and to determine the clinical effectiveness of preemptive avoidance of latex exposure in high-risk patients. DESIGN: Prospective, clinical trial. SETTING: Operative theater of a university hospital. PATIENTS: 95 adult patients. INTERVENTIONS: Patients were preoperatively screened and classified for present latex allergy (high-risk and low-risk group) according to a specially designed screening questionnaire. Anesthesia and surgery in the high-risk group were performed strictly avoiding latex-containing materials. The low-risk group (other allergies including pollinosis) received routine treatment, without latex-avoidance. Effects of latex avoidance or exposure were evaluated by measuring specific IgE titers perioperatively. MEASUREMENTS AND MAIN RESULTS: According to the questionnaire, 45 patients at high risk were defined. Validity of classification of high-risk patients is supported by significantly higher total IgE and latex and grass profilin specific IgE compared to the low-risk group. There were no significant differences in other profilin-specific IgEs. In one case of severe anaphylactic reaction a drop of latex-specific IgE during surgery could be observed. CONCLUSION: The questionnaire allowed the identification of most patients at high risk for latex allergy. In isolated pollinosis no changes in any specific IgE levels were detectable. Strict avoidance of perioperative latex exposure in high-risk patients increases safety during anesthesia and surgery.     

Latex allergy in children with urological malformation and chronic renal failure

PURPOSE: Children with spina bifida, bladder exstrophy and anorectal anomalies are at risk for latex allergy. Severe intraoperative anaphylaxis in a boy treated with kidney transplantation prompted this study to evaluate the prevalence of latex allergy in a cohort of children with chronic renal failure (CRF). MATERIALS AND METHODS: Between 1996 and 2002, 57 boys and 28 girls were investigated at a median age of 10.5 years (range 1.3 to 22.9). Urological malformations were the underlying cause of CRF in 33 patients (39%). Of the patients 39 were on conservative treatment, 20 were on dialysis and 26 had a functioning renal graft. Latex reaction was assessed by a careful history, specific serum latex IgE and skin prick test. RESULTS: A total of 19 patients (22%) showed latex reaction, of whom 8 had allergy (clinical symptoms included severe intraoperative anaphylaxis in 1) and 11 had sensitivity (positive IgE or prick test without symptoms). Of these 19 patients 11 had urological malformations. The number of surgical procedures, young age at operation and atopy were significant risk factors. When operations were analyzed separately, ie urological vs nonurological surgery, only urological surgery was significantly associated with latex reaction. A significant correlation was also found between the overall number of operations and latex radioallergosorbent class. CONCLUSIONS: All children with CRF who undergo early and multiple urological surgery are at high risk for latex reaction. Primary latex prevention, ie the routine use of latex-free gloves, tubes and catheters, should be implemented in all children with complex urological malformations.     

Immunoglobulin e-mediated allergies in lung-transplanted adults

BACKGROUND: Immunoglobulin E (IgE)-mediated allergy has repeatedly been reported after solid organ transplantation, apparently affecting approximately 10% of pediatric organ transplant recipients. Interestingly, type 1 allergy has not been described in transplanted adults, suggesting a particular propensity in childhood. METHODS: The present cross-sectional study assessed the prevalence of type 1 allergy in 42 adult lung transplant recipients aged 25 to 50 years. Instruments included standardized interviews, skin prick tests, and serum IgE measurements. RESULTS: Ten of 42 patients (23.8%) displayed elevated specific IgE levels or positive skin prick test results against one or more allergens. Five individuals (11.9%) additionally reported corresponding clinical symptoms of type 1 allergy. No statistically significant association of sensitization or allergy prevalence with patient age, kind of immunosuppressive therapy, and time since transplantation was found. CONCLUSIONS: The phenomenon of transplantation-associated allergy is not age-restricted and thus should be assessed more thoroughly in all age groups.     

Prevalence and risk factors for latex sensitization among anesthesiologists

BACKGROUND: Although powdered latex surgical gloves are predominantly used in Japanese healthcare facilities, the prevalence of latex sensitization among anesthesiologists has not been investigated. METHODS: The authors surveyed 60 anesthesiologists of 16 facilities with questionnaires and measurements of specific IgE antibodies against latex and other aeroallergens by AlaSTAT microplate immunoassay. Sensitization was defined as positive if the specific IgE concentration was not less than 0.70 IU x ml(-1). RESULTS: With surgical gloves 63.3% of anesthesiologists used powdered latex gloves, compared to 10.2% with examination gloves. The prevalence of latex sensitization was 33.3%, with a peak of 70% (7/10) in ages 45-49. In multivariate analysis, anesthesiologists of the facilities where more than 50% of them used powdered latex surgical gloves had a 6.0-fold risk of latex sensitization (95% CI 1.7-21.5; P=0.006). Histories of atopic dermatitis, asthma, or food allergy were also considered as risk factors (OR 3.8; 95% CI 1.1-13.7; P=0.038). The history of allergic rhinoconjunctivitis was not associated with latex allergen, but with Japanese cedar pollen. No relation was observed between latex and timothy pollen. CONCLUSIONS: Our results suggest that surgical powdered latex gloves were the major predisposing factor for latex sensitization measured by latex-specific IgE among anesthesiologists.     

Latex-related allergy in hemodialysis patients

Abstract

Background: Incidence of allergic reactions is increased in hemodialysis (HD) patients. However, the prevalence of latex allergy is not exactly known in HD patients. The aim of this present study is to determine the prevalence of latex allergy in HD patients. Methods: A total of 205 adult HD patients were included in the study. Questionnaires were completed during patient interviews, and their consents were provided. Latex prick test and latex specific IgE test (HY-TEC, K82) were performed. Mean age of the patients was 52?±?14 (25–79) years, and 61% was male. Mean dialysis duration was 38 months, and 21% of them were diabetics. Only five patients had allergic complaints in their histories, and none of them had severe anaphylaxis history. Latex prick test was positive in two patients. Latex specific IgE test was positive in five patients. Overall latex sensitivity was defined as 3.4%. Conclusion: No increased prevalence in latex allergy was determined in HD patients. Latex allergy incidence may be increased in atopic HD patients. Therefore, the use of latex products should be avoided as much as possible especially in atopic HD patients.     

Is allergen exposure the major primary cause of asthma?

In recent decades a number of authors have argued that allergen exposure is the major primary cause of asthma, and that the global increases in asthma prevalence are due to increases in exposure to aeroallergens. We have assessed the epidemiological evidence in support of this hypothesis. No longitudinal studies were identified in which allergen exposure during infancy in a random population sample has been related to asthma risk after the age of six years. Two studies have been conducted in selected populations chosen on the basis of a family history of asthma or allergy; one study found a non-statistically significant association whereas the other study found no association. Many of the identified prevalence studies in children showed negative associations between allergen exposure and current asthma, and the weighted averages of the population attributable risks in children were 4% for Der p 1, 11% for Fel d 1, -4% for Bla g 2, and 6% for Can f 1. There was little change in these estimates in studies in which children whose parents had adopted allergen avoidance measures were excluded. Furthermore, evidence from population studies is equivocal and provides little consistent evidence that allergen exposure is associated with the prevalence of asthma at the population level. Population-based cohort studies are clearly required, but currently available evidence does not indicate that allergen exposure is a major risk factor for the primary causation of asthma in children.     

Chronic otitis media and immunoglobulin E-mediated hypersensitivity in adults: is it a contributor of cholesteatoma?

OBJECTIVES: The aim of this study was to determine the relationship between chronic otitis media (COM) and immunoglobulin E (IgE)-mediated hypersensitivity in adults. STUDY DESIGN: A prospective comparative study. SUBJECTS AND METHODS: One hundred seventeen patients with COM from July 2005 to April 2007 were enrolled. All subjects had a questionnaire on allergic rhinitis symptoms and performed allergy tests that included a total IgE and the multiple radioallergosorbent chemiluminescence assay to check the presence of IgE-mediated hypersensitivity. RESULTS: The prevalence of IgE-mediated hypersensitivity and allergic rhinitis were 22.2% and 7.7% in patients with COM, respectively. The mean total IgE was 157.2 ranging from 3 to 1833. The prevalence of IgE-mediated hypersensitivity was similar with regard to the recurrence or bilaterality. However, patients with cholesteatoma had a higher prevalence of IgE-mediated hypersensitivity than patients without that condition. CONCLUSION: The prevalence of IgE-mediated hypersensitivity and allergic rhinitis in adults with COM appeared to be higher than in the general population. Allergy might contribute to COM especially in cases with a cholesteatoma.     

Anaphylaxis during Anesthesia in Norway: A 6-Year Single-center Follow-up Study

Background: Several studies have recognized neuromuscular blocking agents as the most common cause of anaphylaxis during general anesthesia, but the reported frequencies vary considerably between countries. In Norway, the issue has raised special concern because of reports from the Norwegian Medicines Agency that suggest a high prevalence. This article presents the results from a standardized allergy follow-up examination of 83 anaphylactic reactions related to general anesthesia performed at one allergy center in Bergen, Norway.

Methods: Eighty-three cases were examined during the 6-yr period of 1996-2001. The diagnostic protocol consisted of case history, serum tryptase measurements, specific immunoassays, and skin tests.

Results: Immunoglobulin E-mediated anaphylaxis was established in 71.1% of the cases, and neuromuscular blocking agents were by far the most frequent allergen (93.2%). Suxamethonium was the most frequently involved substance, followed by rocuronium and vecuronium. The few reactions in which other allergies could be detected were mainly linked to latex (3.6%).