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• W2078448437 abstract "History of allergy to local anesthetics is rare but is particularly problematic in parturients because, during labor, alternatives to local anesthetics may not be as effective. Adverse reactions to local anesthetics are rare (1) and are usually because of the paraben or sulfite preservatives in them. When they do occur, they may range from psychomotor responses to hypersensitivity reactions ranging from immediate type I (immunoglobulin E mediated) to type II and III hypersensitivity (immune complex mechanism) to delayed type IV hypersensitivity (cell-mediated) (2). The following case report illustrates some of the problems in the parturient and makes recommendations regarding the optimal timing and nature of provocative testing. The timing of testing has not been previously discussed. Case Report A 35-yr-old, gravida 3, para 1 parturient at 36-wk gestation with a history of allergy to local anesthetics presented to the obstetric anesthesia service for evaluation. During her first pregnancy, she received a combined spinal epidural (CSE) with 15 μg of intrathecal sufentanil followed by boluses of epidural fentanyl 50–100 μg. She reported poor pain relief during her labor, and she was referred for evaluation of her allergy, but she neglected to follow up. Her medical history was significant for mitral valve prolapse, pericarditis, and deep vein thrombosis. She had received uncomplicated general anesthesia on two occasions. Her reported allergy to “all caines” was based on several experiences: at age 12, she underwent a dental procedure and received a local anesthetic followed by dyspnea, upper airway swelling, and brief syncope treated with subcutaneous epinephrine and oxygen by mask; during bunionectomy under local anesthesia in 1986, she developed bronchospasm and transient respiratory arrest; and she reported transient dysrhythmia after a mepivacaine administration. The patient returned to labor and delivery at 38-wk gestation to undergo provocative challenge with preservative-free (PF) bupivacaine. We followed the methodology of Chandler et al. (3). Provocative challenge testing provides a useful method for rapid identification of a safe local anesthetic for an individual patient. It differs from traditional tests performed by allergists, such as skin testing, drug-specific basophil degranulation, or radioallergosorbent testing, in that it can easily be performed by an anesthesiologist in labor and delivery. It is also not associated with the frequent (8%–15%) false positive rate of intradermal skin testing (3). Before administering the challenge, arrangements were made to have the obstetric team on standby for emergency cesarean delivery should the patient become unstable. After fasting for 12 h, an IV catheter and standard intraoperative monitors were placed. Fetal heart rate was intermittently monitored. Subcutaneous injections of PF 0.25% bupivacaine (Sensorcaine) were administered beginning with 0.1 mL and followed by 0.5-mL, 1.0-mL, and 2.0-mL doses. The patient was observed for 15 min after each injection for clinical signs of allergic reaction. No clinical signs were observed, and there were no skin changes. Labor was induced, and she received a CSE with 1 mL of 0.25% PF bupivacaine and 15 μg of fentanyl intrathecally followed by a continuous epidural infusion of 0.125% PF bupivacaine with fentanyl 1–2 μg/mL. She delivered a normal infant with excellent pain relief during labor and repair of her first-degree perineal laceration. She was given a letter stating that she had undergone the above testing and seemed to be at no greater risk than the general population with adverse reactions to PF bupivacaine. Discussion The superiority of regional anesthesia using local anesthetics to all other analgesic techniques in obstetrics and the fact that its use avoids the complications of general anesthesia in case of cesarean delivery makes suspected local anesthetic allergy in parturients an important issue. Although true allergy (immunoglobulin E mediated) to local anesthetics is rare (incidence of <1%(3)), anaphylactic reactions may prove life threatening for the mother and fetus and may necessitate emergency cesarean delivery. This issue and its implications for optimal timing of testing in the parturient have not been previously addressed. Others have reported the administration of provocative testing as early as 20-wk gestation (4), a practice we would discourage. The safety and utility of provocative challenge testing has been well established (5–7). Our patient had a convincing history for local anesthetic hypersensitivity and failed regional with narcotics alone and desired to receive standard labor analgesia. Although alternatives to standard labor analgesia with local anesthetics such as epidural, spinal, and parenteral opioids have been used successfully in the management of labor pain, our patient’s experience with neuraxial opioids alone for labor was extremely unsatisfactory. As a result of her experience and in light of the fact that she planned to have more children, she expressed a very strong desire to be tested even after a detailed discussion of alternatives. We choose PF bupivacaine as the single local anesthetic to test because of its widespread use and motor-sparing qualities. However, the most critical issue relates to the timing of provocative challenge testing. Although prepregnancy testing is ideal (8), when parturients present early in pregnancy, testing should be postponed until the fetus is viable or later. We also suggest that testing be performed in labor and delivery with preparations for emergent intervention (emergent cesarean delivery) should the patient develop a serious reaction that does not immediately respond to treatment." @default.
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• W2078448437 title "Management of a Parturient with a History of Local Anesthetic Allergy" @default.
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• W2078448437 doi "https://doi.org/10.1213/01.ane.0000058843.24914.c7" @default.
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