Expert: Ronald Levy, M.D. - 3/12/2010

Question
QUESTION: I have severe allergies to most many medications and food and latex and soy, I have a Medic Alert bracelet and ERIR sheet I take to every medical appointment. My question is this, because I have these extensive and severe reactions (almost died several times) and I need surgery for possible malignant thyroid "hurthle cell" neoplasm, can you suggest where would be the best plan for my having surgery and anesthesia safely? Is there a major medical center that could best help me have a safe surgery? I am going to MDAnderson/Orlando Regional now, but they only provided me a list containing 3 possible induction medications: Propofol, Lidocaine and Rocuronium. Also preoperative medication possibilities of: Fentanyl, Versad (I may have had this previously/successfully for colonoscopy) Pepcid, Reglan, Zofran. Then they listed other possible medications that may be given during surgery as Neosynephrine, Ephedrine, beta blockers, Decadron, antibiotics.

I am trying to have skin allergy testing for possible general anesthesia prior to surgery and I have an allergist who may do this for me, but I need more information. I have chronic illness including asthma and I want to avoid any allergic reactions at all costs. Can you suggest a protocol for pre-medication? I need an want the surgery but I am terrified of a serious allergic reaction. Many years ago I had two surgeries and was only very nauseous afterwards. But I was not so ill back then and did not have all of these awful reactions/allergies. I can have/and have had Lidocaine without epinephrine or preservatives with no problem (was tested for locals). I am very allergic to antibiotics, only known safe antibiotic I can take currently is Levequin. Can Lidocaine be used as a general anesthesia? I have asked to speak with the anesthesiologist now, but they have only provided me with a list, then a several days before surgery I would meet with the anesthesiologist. This is a very serious matter for me, I react severely to most things people never have a problem with. I have autoimmune disease and long term chronic Lyme (no successfull treatment due to antibiotic/severe reactions). I have considered no surgery as an option (and I also need other surgeries for cervical problems).

I know this is overwhelming but I really need answers. Should I go to MDAnderson at the University of Texas for another opinion, or somewhere else where they may a lot of knowledge of allergies with anesthesia? I will travel if necessary. Any answers or suggestion you might have will be most gratefully appreciated. I do not want to be a pest/annoy my current doctor's office with too many questions.

ANSWER: Generally speaking, if you have never been exposed to a drug, then if you are allergic to it the reaction is mild. The 3 drugs you called induction medications are actually an induction med (Propofol) a local aneshtetic (Lidocaine) and a paralytic (Rocuronium). Fentanyl is a narcotic, Versed is an anxiolytic, neosynephrine nad ephedrine are vasopressors (raise your blood pressure), beta blockers slow your heart and Decadron is a steroid.

As for where to have the surgery, no place "specializes" in patients with allergies. I would recommend going to a major university hospital (as opposed to a community hospital) but any anesthesiologist is competent to treat potential allergic reactions. In fact, the best place to have an allergic reaction is the OR because we are always prepared for that possibility. Since you have had Versed/Fentanyl in the past, that is fine for a pre-medication. The other agents mentioned are also appropriate as you are likely to have never been exposed to them before. I don't think it's necessary to travel a great distance to have this done. Find a local University or teaching hospital to have your surgery and don't worry.

Ronald Levy, MD
Professor of Anesthesiology
UTMB-Galveston

---------- FOLLOW-UP ----------

QUESTION: Thank you so very much for your very kind, informative and speedy answer. I would love not to worry about this, but experience has taught me I need to be my own best advocate. For instance, the information I asked listed Licocaine, Propofol, Rocuronium as Induction Medications. Thanks to your very kind response I have learned I do not have the correct information yet to give to my allergist. Again, my many allergic reactions were very serious, and one was very prolonged, extremely painful and frightening. I am allergic to soy on every allergy test I have had, both skin and RAST (many) except one. I have reactions went I ingest it, rashes, boils, some asthma. Since soy is in Propofol in the form of "soy oil" (?) I do not know if this would be a good choice for me? My allergist's office asked me to get the names of several general anesthesia medications so that they can order and test me for them.
This place where I am going currently MD Anderson at Orlando Regional Medical Center. The hospital is a trauma level 1 center (which would be a great place to be in the event of an allergic reaction). I am really trying to avoid any reaction at all, and overcome my fear of major surgery. I guess I need to contact the surgeon's office again about all this, get more information on the other general anesthesia possibilities?

You are doing a wonderful service. Thank you again. If you can comment further as to any other possible general anesthesia that would not be soy, nut based, that would be greatly appreciated! Oh, two other questions, do these medications have preservatives, iodine or sulfites in them, and are patients ever pre-medicated to avoid allergic reactions now a days?

Answer
Generally the allergy with Propofol is related to the Egg lecithin but since you do have a severe allery to soy, it is probably best not to get Propofol. Several other options include Thiopental, Etomidate, Methohexital and Ketamine.

The drugs are listed as induction agents because they are used during the induction phase of anesthesia but technically, the induction agent is the agent that puts you to sleep and only Propofol does that. As for preservatives, your best bet would be to contact the drug companies. I am not aware of any preservatives but I won't swear to that so contact the individual companies for that information.

We don't premedicate for allergies as it has not really shown to be that effective. We just avoid those agents that we know the patient is allergic to. It is very easy to treat once it manifests so we prefer that approach.

Ronald Levy, MD
Professor of Anesthesiology
UTMB-Galveston