Recommended Citation
Bawdane K, Nasr N, Inozemtsev K, Cao N. I would like an epidural, and oh, by the way, I'm allergic to local anesthesia!. Presented at: Midwest Anesthesia Residents Conference (MARC); April 26, 2025; Indianapolis, IN.
Presentation Notes
Presented at: Midwest Anesthesia Residents Conference (MARC); April 26, 2025; Indianapolis, IN.
Abstract
Introduction: Allergies to local anesthetics (LAs) are rare [1] but can present significant challenges in patient management, particularly for laboring patients seeking neuraxial analgesia. While there is limited cross-reactivity between amide and ester LAs, significant cross-reactivity can occur within the same class, especially among ester LAs. This case illustrates a safe approach to testing and administering LAs in a patient with an allergy to an unknown LA. Case Presentation: This case involves a 20-year-old female, G1P0 at 40 weeks and 0 days gestation, with a medical history of gestational hypertension and obesity (BMI 36), who was admitted to the labor and delivery department requesting labor analgesia. During the pre-procedure evaluation, the patient disclosed that she had recently undergone two deep dental cleanings where LAs were administered. Approximately 1–2 hours after receiving LAs on both occasions, she developed full-body hives, which improved after taking diphenhydramine. The patient was unsure which LA was used and had never received LAs before her recent dental procedures. She had not undergone formal allergy testing following these reactions. Given this history, the anesthesia team consulted an allergist, who recommended performing a scratch skin test with commonly used anesthetic agents, including 1% lidocaine, 3% 2-chloroprocaine, 0.5% ropivacaine, and 0.25% bupivacaine. All tests were negative except for lidocaine, which caused localized erythema, swelling, and pruritus. This reaction was interpreted as a true allergy to lidocaine. The allergist then advised performing intradermal testing with the LAs that had negative scratch test results, all of which were non-reactive. Based on these findings, the allergist and anesthesia team determined that it was safe to administer LAs neuraxially, except for lidocaine. The patient subsequently required a cesarean delivery due to failed induction of labor. The anesthesia team opted for a single spinal shot with 1.4 mL of 0.75% hyperbaric bupivacaine, along with 15 mcg of fentanyl and 150 mcg of morphine. Additionally, 3 mL of 0.25% bupivacaine was used to numb the skin at the injection site. No pre-medications were given, and ERAC protocol was followed. The spinal block provided excellent analgesia, with no signs of an allergic reaction during or after the procedure. Conclusion: Ideally, patients with a similar history should undergo formal allergy testing outpatient before presenting for delivery. However, anesthesiologists may encounter situations like the one described, which present unique challenges and considerations. This case demonstrates a safe approach to identifying and managing patients with a suspected allergy to an unknown LA. It suggests that LAs can be safely administered neuraxially following negative scratch and intradermal skin tests [2]. 1. Bhole, M. V. et al. (2012) British Journal of Anaesthesia 108:903-911 2. Arya, V.et al.(2021) J Dent Anesth Pain Med 21(6):583-587
Type
Poster
Affiliations
Advocate Illinois Masonic Medical Center