Alpha-gal Syndrome and perioperative concerns

Answer:
Thank you for your question.

The concern for perioperative risk in alpha-gal patients is intraoperative exposure to non-primate mammalian compounds. Some perioperative medications such as heparin, gelatin, glycerin or stearate; as well as surgical products including porcine-derived heart valves, xenografts, surgical powder, surgifoam powder, catgut suture, bio-mesh, and thrombin. There are several reports of allergic reactions with high dose heparin during cardiac by-pass surgery. It is hypothesized that the underlying cause at least a portion of allergic reactions to heparin allergy may indeed be alpha-gal syndrome. As heparin is derived from bovine lung and porcine intestinal mucosa, it may contain the α-gal epitope as a result of a potential contamination during the manufacturing process. (1-3)

I only found one reference addressing premedication prior to surgery. Sell-Dottin K, et al (3) presented 5 cardiac surgery cases and a brief review of the literature. The authors endorsed preoperative and intraoperative steroids and diphenhydramine, in addition to careful avoidance of products known to contain or cross-react with non-primate mammalian meats. While this practice is anecdotal, it should not be viewed as standard practice.

The most important preoperative intervention is clearly identifying the patient as having alpha-gal syndrome. Make certain there the preoperative team, surgical team, anesthesia team and perioperative nursing staff is aware of the significance and clear guidance on products that pose risk. This is imperative to assure patient safety throughout the perioperative course.

1) D’Ercole FJ, Dhandha VH, Levi ML, et al. Perioperative challenges in patients with alpha-gal allergy. J Clin Anesth Pain Manag. 2019;3(1):70-78.
2) Dewachter P, Kopac P, Laguna JJ, Mertes PM, Sabato V, Volcheck GW, Cooke PJ. Anaesthetic management of patients with pre-existing allergic conditions: a narrative review. Br J Anaesth. 2019 Jul;123(1):e65-e81. doi: 10.1016/j.bja.2019.01.020. Epub 2019 Mar 13. PMID: 30916009
3) Dunkman WJ, Rycek W, Manning MW. What Does a Red Meat Allergy Have to Do With Anesthesia? Perioperative Management of Alpha-Gal Syndrome. Anesth Analg. 2019 Nov;129(5):1242-1248.
4) Kristen A Sell-Dottin, et al. Impact of Newly Emerging Alpha-Gal Allergies on Cardiac Surgery: A Case Series. Clinics in Surgery. 2017 | Volume 2 | Article 1477

I hope you found this helpful.

Respectfully submitted,
Jeffrey G Demain, MD, FAAAAI