How should I evaluate and manage a surgical patient with a reported drug (e.g., antibiotic, neuromuscular‑blocking drug) or latex allergy peri‑operatively, including allergy history, avoidance, pre‑operative testing, pre‑medication, intra‑operative preparedness, anesthetic choice, postoperative monitoring, and desensitisation if needed?

Perioperative Allergy Management

For any patient with a reported drug or latex allergy, obtain a detailed allergy history during pre-operative assessment—well before entering the operating room—and if the history suggests previous perioperative anaphylaxis or is equivocal, refer for allergy testing before elective surgery; avoidance of the culprit agent and cross-reactive drugs is mandatory, as one-third of patients will experience recurrence if the offending agent is not identified. 1, 2

Pre-operative Allergy History Assessment

Timing is critical: Verify allergy status during the "Sign-in" phase before induction of anesthesia, not during timeout when the patient has already been exposed to potential allergens. 2

Essential Questions to Ask

• Previous anaphylactic reactions: Specifically ask about prior perioperative collapse, severe bronchospasm, cardiovascular instability, or widespread urticaria during any previous anesthetic. 1, 2
• Latex exposure history: Ask about reactions to balloons, condoms, latex gloves causing itching, rash, or angioedema. 1
• High-risk latex populations: Healthcare workers, children with spina bifida or multiple prior surgeries, patients with severe hand dermatitis, atopic individuals, and those with allergies to banana, chestnut, or avocado. 1, 3
• Drug allergies: Document all reported antibiotic allergies (especially penicillins), neuromuscular blocking agent reactions, and any adverse events with local anesthetics. 4
• Occupational history: Industrial workers using protective gear have increased latex sensitization risk. 1

Documentation Requirements

• Record allergy information in both the electronic medical record and on a patient wristband. 1, 2
• Place "Latex Allergy" notices on doors to the anesthetic room and operating theater if latex allergy is confirmed. 1

Pre-operative Testing Indications

If the clinical history is positive or equivocal for previous perioperative reaction, refer the patient for allergy testing before elective surgery; proceed only in emergencies. 1

Testing Options

• Latex allergy: Either latex-specific IgE blood testing or skin prick testing (sensitivity 75–90%; skin prick testing may be more sensitive than blood tests). 1
• NMBA allergy: Skin testing for all available neuromuscular blocking agents to identify the culprit drug and assess cross-reactivity. 1, 5, 6
• Important caveat: Skin tests must be performed by trained staff with resuscitation facilities immediately available. 1

When Testing is Not Available

If previous anesthetic records are unavailable or testing cannot be performed before emergency surgery, implement the following avoidance strategy: 1

Anesthetic Management Based on Allergy Type

Neuromuscular Blocking Agent (NMBA) Allergy

NMBAs are the leading cause of perioperative anaphylaxis in most countries, with rocuronium and succinylcholine most frequently implicated. 1, 5, 7

Avoidance Strategy

• If a specific NMBA caused the previous reaction: Avoid all neuromuscular blocking drugs if possible because cross-sensitivity is common (75.7% overall cross-reactivity). 1, 8
• Cross-reactivity patterns: Rocuronium shows 85.3% cross-reactivity with vecuronium due to structural similarity, 50% with cisatracurium, and only 12.5% with succinylcholine. 8
• Alternative approach: Consider regional or inhalational anesthesia techniques to minimize intravenous drug exposure. 2
• If NMBAs cannot be avoided: Use only agents that tested negative on skin testing, but recognize that 20% of patients may still experience hypotension despite negative skin tests. 8

FDA-Labeled Precautions

• Atracurium: Request information about previous anaphylactic reactions to other NMBAs; severe anaphylactic reactions have been reported. Use lower initial doses (0.3–0.4 mg/kg) in patients with history suggesting greater risk of histamine release. 9
• Rocuronium: Contraindicated in patients with hypersensitivity to rocuronium or other NMBAs; consider cross-reactivity. 10
• Succinylcholine: Request information about previous anaphylactic reactions; allergic cross-reactivity has been reported in this class. 11

Latex Allergy

Approximately 8% of the population is sensitized to latex, but only 1.4% exhibit clinical allergy; avoidance is mandatory if latex allergy is diagnosed. 1, 3

Peri-operative Latex Precautions

• Operating room preparation: Prepare the theater the night before to allow latex particles to settle; schedule the patient first on the list. 1, 2
• Complete latex avoidance: Use only synthetic (nitrile or vinyl) gloves for all equipment preparation, anesthesia, surgery, and post-operative care. 1, 2
• Environmental control: Remove all latex-containing items (rubber dams, certain blood-pressure cuffs, latex gloves) from the treatment area. 4
• Team notification: Alert the surgical team, nursing staff, and anesthetic support teams. 1
• Equipment verification: Ensure resuscitation boxes contain only latex-free materials. 1

Antibiotic Allergy

Antibiotics are a leading cause of perioperative anaphylaxis alongside NMBAs. 1, 7

Management Strategy

• β-lactam allergy: If the patient reports IgE-mediated penicillin reaction (urticaria, angioedema, bronchospasm, anaphylaxis), avoid all β-lactam agents including first-generation cephalosporins and cefamandole due to shared side chains. 4
• Safe alternatives: Clindamycin, azithromycin, or metronidazole. 4
• Important note: Patients with antibiotic-induced immediate hypersensitivity have 1.77 times higher risk of positive skin tests for NMBAs compared to controls. 12

Local Anesthetic Allergy

True IgE-mediated allergic reactions to amide local anesthetics (lidocaine, bupivacaine, mepivacaine) are extremely rare, representing <1% of all reported adverse events. 1, 4

Safe Practice

• Amide local anesthetics are likely safe: Allergy to amide drugs is exceedingly uncommon. 1
• Preservative-free formulations: Further reduce risk of reactions to methylparaben or metabisulfite additives. 4

Chlorhexidine and Antiseptic Allergy

Chlorhexidine reactions are increasing with widespread use as a disinfectant. 1

Alternative Approach

• If chlorhexidine allergy is suspected: Avoid chlorhexidine preparations; allergy to povidone-iodine is less common. 1

Opioid and Histamine-Releasing Drug Reactions

If the previous reaction may have been non-allergic anaphylaxis, avoid drugs known to release histamine, such as morphine. 1

Intra-operative Preparedness

Prophylactic Premedication

There is no evidence that premedication with antihistamines or steroids is useful in preventing anaphylaxis; do not rely on prophylactic medications. 1, 4

Monitoring and Treatment Readiness

• Peripheral nerve stimulator: Essential for assessing neuromuscular block, especially in patients with myasthenia gravis, Eaton-Lambert syndrome, or other neuromuscular diseases. 9
• Immediate availability: Ensure facilities for intubation, mechanical ventilation, oxygen therapy, and reversal agents are immediately accessible. 10
• Recognition and treatment: Most perioperative anaphylaxis is recognized promptly; rapid epinephrine administration is critical (mortality rate 3–9% when treatment is delayed). 1, 7

Post-operative Investigation

If intra-operative anaphylaxis occurs, the patient must undergo comprehensive allergy testing 4–6 weeks after the event to identify the culprit agent and assess cross-reactivity. 1, 6

Testing Protocol

• Mast cell tryptase: Measure during the acute event and at baseline to confirm IgE-mediated mechanism. 1
• Skin testing: Perform intradermal tests for all drugs administered, including all available NMBAs to identify safe alternatives. 6
• Provocation testing: May be appropriate for latex allergy if skin testing is negative or equivocal in the presence of suggestive history. 1

Critical Pitfalls to Avoid

• Never proceed with elective surgery if allergy history is incomplete or suggests previous perioperative reaction without completing allergy investigation. 2
• Do not assume skin test negativity guarantees safety: 20% of patients with negative NMBA skin tests still experienced hypotension upon re-exposure. 8
• Avoid misdiagnosing Phase II block: Use peripheral nerve stimulation before administering anticholinesterase agents, as they will potentiate Phase I block. 11
• Do not underestimate cross-reactivity: 75.7% cross-reactivity exists among NMBAs; testing all available agents is mandatory. 8
• Remember that 17% of NMBA anaphylaxis patients have no prior NMBA exposure: Sensitization may occur through environmental quaternary ammonium compounds. 8