Allergies

In the operating room, allergies are a really big deal. It makes sense. An anesthetized patient won't be able to stop someone from giving an antibiotic that causes a reaction or using latex gloves or prepping the skin with iodine based solution. And a surgery is where someone will receive the highest number of different drugs in the shortest period of time. So allergies have become a part of my daily routine; I ask about it, the pre-op nurse asks about it, the circulator asks about it, and it's reviewed in the time-out.

But I think we've made allergies into too big of a thing. Most of the allergies I encounter aren't true allergies. Many patients come in with the vague story, "My mother told me I reacted to penicillin," and a big permanent "Allergy: PCN" gets put into the record. But the truth is, of the 5-10% of patients reporting a penicillin allergy, only 10-15% have a positive skin test. The problem is that often surgeons choose different peri-operative antibiotics for "penicillin allergic" patients. And if those patients don't truly have a serious reaction, that's doing them a disservice; clindamycin and vancomycin have a poorer risk-benefit profile than the typical cephalosporin. I encourage surgeons to stick with their routine cephalosporin unless the allergy is a verified serious reaction. (Plus, although this is not good justification, if you were to have an allergic reaction, you might as well have it in the operating room with full monitoring and an anesthesiologist who can administer epinephrine.)

The other thing that bothers me about allergies is that medication side effects are often listed as allergies. I have seen too much of "Allergy: Vicodin causes nausea." All the opiates have the side effect of nausea, but this is not an allergic reaction mediated by immunoglobulins or T-cells. And if used correctly, opiates could be perfectly appropriate for the patient. But once this makes it onto the chart, it is incredibly hard to change. It's of course not the patient's fault, but I hope  the person putting the allergies into the record understands the impact of what they're doing.

The most extreme example of this is a patient I saw who had an allergy to epinephrine - it causes palpitations. As this is one of the direct effects of epinephrine, it's hardly an allergy at all. The danger is that epinephrine is the treatment for a true allergic reaction, anaphylaxis. Such things drive me crazy.