A "Rash" Decision in Anesthetic Management: Benzyl Alcohol Allergy in the Perioperative Period.

Here, we present the case of a 54-year-old female presenting for outpatient ankle hardware removal who experienced severe total body pruritus along with a maculopapular rash persisting four days after the procedure. Patch testing demonstrated a sensitivity to benzyl alcohol, a preservative in propofol and several other anesthetics. The patient returned for left ankle arthroscopy a year later, and during that procedure, the anesthetic team avoided medications containing benzyl alcohol. This resulted in no pruritus or rash. Hypersensitivity reactions, ranging from contact dermatitis to anaphylaxis, are critical events in the perioperative period. Induction of general anesthesia has been implicated as the inciting event for perioperative hypersensitivity reactions. Benzyl alcohol is among a few excipients found in common anesthetic agents known to cause hypersensitivity reactions in susceptible patients. While reports of adult death are rare, infantile death due to benzyl alcohol has been described.

Pharmacogenetics in Practice: Estimating the Clinical Actionability of Pharmacogenetic Testing in Perioperative and Ambulatory Settings.

Most literature describing pharmacogenetic implementations are within academic medical centers and use single-gene tests. Our objective was to describe the results and lessons learned from a multisite pharmacogenetic pilot that utilized panel-based testing in academic and nonacademic settings. This was a retrospective analysis of 667 patients from a pilot in 4 perioperative and 5 outpatient cardiology clinics. Recommendations related to 12 genes and 65 drugs were classified as actionable or not actionable. They were ascertained from Clinical Pharmacogenetics Implementation Consortium (CPIC) guidelines and US Food and Drug Administration (FDA) labeling. Patients displayed a high prevalence of actionable results (88%, 99%) and use of medications (28%, 46%) with FDA or CPIC recommendations, respectively. Sixteen percent of patients had an actionable result for a current medication per CPIC compared with 5% per FDA labeling. A systematic approach by a health system may be beneficial given the quantity and diversity of patients affected.

Pharmacology of Octreotide: Clinical Implications for Anesthesiologists and Associated Risks.

Many patients presenting with a history of foregut, midgut neuroendocrine tumors (NETs) or carcinoid syndrome can experience life-threatening carcinoid crises during anesthesia or surgery. Clinicians should understand the pharmacology of octreotide and appreciate the use of continuous infusions of high-dose octreotide, which can minimize intraoperative carcinoid crises. We administer a prophylactic 500-µg bolus of octreotide intravenously (IV) and begin a continuous infusion of 500 µg/h for all NET patients. Advantages include low cost and excellent safety profile. High-dose octreotide for midgut and foregut NETs requires an appreciation of the pathophysiology involved in the disease, pharmacology, drug-drug interactions, and side effects.