Egg Anaphylaxis and Propofol

A few months ago Dr. Ed Goroza asked an interesting question:

How do sedation providers approach the child with a history of anaphlyaxis to eggs when it comes to the use of propofol?

While most anesthesia texts and “experts” in the field do not think that egg-allergy is a true contraindication to the use of propofol, it still seems that many are reluctant to use it in the egg allergic patient.

Anesthesia and Analgesia

The science

Here is an exert from Anesthesia & Analgesia that highlights some of the current science surrounding the issue:

Propofol was originally formulated with the surfactant Cremophor EL, but a series of hypersensitivity reactions prompted a change in the formulation (36,71,72). Propofol (2,6-diisopropylphenol) is currently formulated in a lipid vehicle containing soybean oil, egg lecithin, and glycerol. The incidence of anaphylactic reactions with the new formulation is 1 in 60,000, although it has been reported to cause 1.2% of cases of perioperative anaphylaxis in France (73). A more recent report from the same group in France demonstrated that 2.1% of cases of intraoperative anaphylaxis are due to propofol (5). In a report of 14 patients with documented propofol allergy on first exposure, the 2 isopropyl groups of the propofol were thought to be the sensitizing epitopes (36). Isopropyl groups are present in dermatologic products and may account for anaphylactic reaction to propofol on the first exposure. In addition, there is a report of an anaphylactic reaction to propofol at the time of the third exposure to the drug (72). Phenol may have acted as an antigen and produced sensitization that led to an episode of anaphylaxis on reexposure. Most cases of drug allergy to propofol are IgE mediated, and specific IgE RIA and intradermal skin tests have been reported (36).

Propofol is formulated in a lipid emulsion containing 10% soybean oil, 2.25% glycerol, and 1.2% egg lecithin. The egg lecithin component of propofol’s lipid vehicle is a highly purified egg yolk component (74). Ovalbumin, the principal protein of eggs, is present in the egg white. Skinprick and intradermal testing with propofol and with its lipid vehicle (Intralipid) were negative in 25 patients with documented egg allergy (74). The measles-mumps-rubella vaccine does contain small amounts of egg-related antigens (ovalbumin), which are grown in cultures of chick-embryo fibroblasts. However, the measles-mumps-rubella vaccine has been given to egg-allergic children without any episodes of anaphylaxis (75). Therefore, current evidence suggests that egg-allergic patients are not more likely to develop anaphylaxis when exposed to propofol.

As is often the case, the science of medicine does not always correlate with the practice of medicine.  Dr. Goroza surveyed the SPS listserve and the results of that survey are listed below.

Dr. Goroza’s Survey

The practice

Of the 11 responders, only 3 would still give propofol & only if there was no prior reaction to the drug. The majority of the responders would not give propofol and would instead use (some would use more than one method): barbiturates (3 responses), dexmedetomidine alone (3), dexmedetomidine with ketamine (2), benzodiazepine (2), barbiturate with opioid (1) and ketamine alone(1).

It is interesting to note that there is very little  published literature describing this topic. I was able to find the two below:

  1. De Leon-Casasola et al. Anaphylaxis due to propofol. Anesthesiology. 77:384-386,1992.
  2. Hofer. Possible anaphylaxis after propofol in a child with food allergy. Annals of Pharmacotherapy. 37(3):398-401, 2003.

It seems agreeable that the choice of not using propofol in these situations is driven by concerns over liability. The association is perhaps rare that I have yet to meet an anesthesiologist who has seen one.

Ed Goroza

What would you do?

Please leave a reply below and tell us how you would handle this situation.

10 thoughts on “Egg Anaphylaxis and Propofol

  1. Robert C. Stough, M D

    If we are discussing sedation for MRI for instance, I would use ketamine/precedex as my preferred sedation method. If induction of anesthesia, then inhalation induction with precedex augmentation.

  2. Joel Saltzman, MD

    Without question, I would and do give Propofol to Egg allergic children. While emergency medications and equipment are always available, we have never treated or had an allergic reaction in one of these patients. We did have a child exposed to 50 or more anesthestics involving Propofol, who developed a mild allergic reaction; treated with Diphenhydramine.

  3. Jay Shayevitz

    I have never encountered anyone who experienced anaphylaxis from eating eggs. I have never encountered anyone who experienced anaphylaxis with propofol who claims “egg allergy.” I do not withhold propofol from patients who say they have “egg allergy.”

    I have had an experience with one patient who had wheezing after being given propofol on several separate occasions. This patient had posterior urethral valves, prune belly, ESRD, and was on chronic hemodialysis. He did not have “egg allergy.”

  4. reva raju

    i had a patient recently on whom we used propofol and ended up cxing the case due to bronchospasm. We could not dtermine the reason except the presence of allergy to propofol .

  5. Amy

    In response to Jay Shayevitz, I work throughout our hospital doing sedations. My son is egg allergic and has had an anaphylactic reaction when he ate them. He was then tested and we found out he was allergic. In our facility, we do not give propofol to kids who are egg or soy allergic. We instead use ketamine or fentanyl/versed.

  6. james fletcher

    If there is a history of documented anaphylaxis to eggs, I would avoid tempting fate with propofol, and would select any of the many other options. More commonly, ‘egg allergy’ refers to an eczema-like reaction. In these patients I am happy to use propofol. I my mind the question is not only ‘how likely will something go wrong’ (not likely), but also ‘how hard will it be to fix’

  7. LeRoy

    I always do to my patients what I would want done to one of my family members. In this case, I would not administer diprivan to an egg-allergy patient. Sure, the chance of this patient having a reaction is low but I do not want my patient to be included in the intraoperative anaphylaxis percentage. Why take the chance when other options are available unless you are so hard headed and think you are God and can save everyone!

  8. JNB

    Since the egg protein individuals are allergic to is isolated within the whites and propofol is made from the letcithin of the yolk, patients should not have a reaction to a propofol exposure. However, it is theorized that some of the whites could contaminate a propofol emulsion and therefore cause a response. What we do in our mobile dental anesthesiology practice where we use propofol daily, is ask patients if they can consume baked goods and this will tell us whether a small challange of the protein will indeed cause an anaphylaxis reation. When baked goods are made, the yolks are separated from the whites and are used in the baking process, but the yolk is most definitely contaminated with some of the whites during the seperation process. So, individuals that can eat baked goods without a response can most definitely use propofol, even if there is a small protein contaminant. Protein contamination also is extremely unlikely because it would be destroyed during the processing of the propofol. We have clinically used this protocol to treat many many patients and have never have a reaction. If a patient indicates that they can not eat baked goods, we assume they have a true anaphylaxis allergy to the protein found in egg whites.

  9. Tony

    Plain and simple. Whether or not the science is there to say otherwise, as of now, allergy to eggs, egg products, soy and soy products are listed as contraindications in the drug information sheet included with Propofol.
    Regardless of the science, if something untoward happened to your patient (even something unrelated such as anaphylaxis to latex, NMB, etc), you have no leg to stand on.

    An attorney only simply has to read the DIS to the jury verbatim. Might as well write the check ahead of time and save everyone the trouble.

    There’s alot of ways to do anesthesia. Pick something else.

  10. mom4tiara

    My daughter was in surgery today and propofol was the drug of choice. I found out from another Dr that propofol contained eggs. My daughter has a egg white allergy. Thank goodness she didn’t show any allergic reaction. She has used propofol in the past. My concern is if I’m taking a chance each time she use it.

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