Q:

6/9/2014
I have a patient 73 years old with a history of anaphylaxis to fish and Aleve. A tryptase level was obtained and noted to be 12. She is scheduled for surgery and can have either a local anesthetic or general with Propofol and Sevoflurane anesthesia. Does this patient need to be premedicated to prevent anaphylaxis similar to dye? If premedication is necessary what protocol should be used?

A:

Thank you for your inquiry.

Neither a reaction to fish nor naproxen would indicate a need for premedication prior to surgery. However, a tryptase of 12 is perhaps at least slightly worrisome. As you know, a tryptase of 11.7 or higher is suggestive of mastocytosis in patients who have experienced anaphylaxis to insect stings, and such patients should be evaluated for the presence of mastocytosis. Two previous reactions in your patient plus a tryptase level of 12 therefore forces you to at least consider the possibility of mastocytosis in your patient. I think that it is, of course, highly unlikely that your patient does have mastocytosis, but must at least mention this to you in view of the tryptase level.

Whether or not to evaluate your patient for the presence of mastocytosis with at least a screening test (816V mutation analysis on peripheral blood) or even a bone marrow, would of course be left to your discretion. But I felt it important to at least mention this to you since you specifically asked whether or not this patient was at increased risk for an anaphylactic event (requiring pretreatment).

In answer to your question as to whether or not pretreatment would be helpful, in general pretreatment for perioperative reactions is not as helpful as we would like (1, 2). This appears to be especially true for anaphylactic reactions to latex. I would not therefore personally consider pretreatment for this patient.

I would, however, consider, as noted, at least a screening test for mastocytosis and mentioning to the anesthesiologist that the tryptase was very slightly elevated (or at a borderline level) and that the patient had experienced two previous episodes of anaphylaxis.

In addition, there is an excellent review of the management of mastocytosis in patients undergoing surgery. For your convenience, I have copied the abstract below.

Thank you again for your inquiry and we hope this response is helpful to you.

Guidelines for safe surgery in patients with systemic mastocytosis.
Authors: Chaar CI, et al.
Journal: Am Surg. 2009 Jan;75(1):74-80.
Affiliation: Department of Surgery, Section of Hematology, Yale University School of Medicine, New Haven, Connecticut 06510, USA.
Abstract
Systemic mastocytosis (SM) is a rare disorder with important perioperative implications. The physiological stress of operative procedures and a variety of anesthetic and analgesic medications can be triggers of acute exacerbation of this condition. We present two patients with systemic mastocytosis. One underwent open left inguinal hernia and umbilical hernia repair and the other laparoscopic ventral hernia repair. The literature for perioperative management of patients with SM is extensively reviewed. Both patients were treated preoperatively with intravenous antihistamines and steroids to minimize SM reactions. The first patient underwent uneventful open left inguinal hernia repair and umbilical hernia repair under spinal anesthesia. The second patient underwent general anesthesia. A composite mesh was used to repair a 9 x 12-cm Swiss cheese incisional hernia at the site of previous surgery. After the administration of neostigmine and glycopyrrolate, she developed a generalized rash without any hemodynamic instability. The patient was treated with intravenous Solu-Medrol and Benadryl and was extubated successfully and had an unremarkable postoperative course. Patients with SM require careful perioperative management for surgery under spinal and general anesthesia. These patients can undergo surgical procedures safely and effectively without compromising the standard of care.

1. Lieberman P: Anaphylactic reactions during surgical and medical procedures. J Allergy Clin Immunol. 2002 Aug;110(2 Suppl):S64-9. Review.

2. Lieberman P: The use of antihistamines in the prevention and treatment of anaphylaxis and anaphylactoid reactions. J Allergy Clin Immunol. 1990 Oct;86(4 Pt 2):684-6. Review.

Sincerely,
Phil Lieberman, M.D.

AAAAI - American Academy of Allergy Asthma & Immunology