Anesthesiologists may encounter difficulties when dealing with patients who have multidrug allergies to anesthetic agents. We discuss the perioperative management of a patient with sensitivity to multiple anesthetic agents.

A 65-year-old hypertensive female with lumbar canal stenosis was scheduled to undergo elective multilevel lumbar fusion under general anesthesia. The patient did not reveal any drug and food allergies or surgeries in the past during the preanesthetic visit. In the operating room (OR), a five-lead electrocardiogram, a noninvasive blood pressure monitor, and a peripheral pulse oximeter were connected, and baseline vitals were recorded (heart rate: 86 bpm, blood pressure: 130/90 mm Hg, oxygen saturation: 100%). The patient was induced with intravenous (IV) fentanyl (2 µg/kg), propofol (2 mg/kg), and cisatracurium (0.2 mg/kg). Immediately after tracheal intubation, a high peak airway pressure (40 cm H2O) was noted, and systolic blood pressure dropped to 60 mm Hg. Diffuse rashes were observed all over the body ([Fig. 1a, b]), and the diagnosis of drug-induced anaphylaxis was considered in the presence of hypotension, bronchospasm, and body rash. Immediately, IV chlorpheniramine (20 mg), hydrocortisone (100 mg), and subcutaneous adrenaline (0.5 mg) were administered. The hemodynamics (heart rate: 100 bpm, blood pressure: 130/80 mm Hg) were stabilized with noradrenaline infusion (0.05 μg/kg/min). Following a multidisciplinary meeting with the patient's relatives, the surgery was abandoned. The patient was slowly weaned off the vasopressor, and the trachea was extubated in the intensive care unit (ICU). The patient was discharged from the hospital after being advised to undergo intradermal allergy testing. After 4 months, the patient had intradermal allergy testing, which revealed sensitivity to thiopentone, propofol, morphine, vecuronium, atracurium, cis-atracurium, cefuroxime, and vancomycin. Betadine also demonstrated sensitivity in terms of surgical solutions. However, intradermal testing indicated no sensitivity to fentanyl and local anesthetics. Extensive drug testing was not performed due to the patients' financial constraints. The patient was planned for lumbar fusion surgery, and the repeat anaphylaxis risk was explained by conducting a multidisciplinary meeting with the family members. As the patient was on levofloxacin and paracetamol preoperatively without any issues, the same were planned for antibiotic prophylaxis and analgesia, respectively. The OR members were communicated with and made aware of the anaphylactic risk. An awake radial arterial access was secured as a precautionary measure, and gas induction was performed using 8% sevoflurane along with an oxygen-nitrous oxide (1:1) mixture. To suppress the laryngoscope response, 250 μg IV fentanyl was administered, and tracheal intubation was performed at 2.0 minimal alveolar concentration (MAC) without the use of neuromuscular blocking drugs. Before the skin incision, IV levofloxacin (500 mg) was administered, and 10% chlorhexidine was used instead of betadine. The OR members were instructed to use latex-free gloves. The anesthesia was maintained with sevoflurane (MAC 1.5) and fentanyl target-controlled infusion (Bergmann model, effect site: 1.5 ng/mL), without a neuromuscular blocking drug, and a bispectral index value of 40 to 50 was maintained. Under the surgical drapes, the patient was constantly examined for skin rashes. The patient had stable hemodynamics throughout the procedure, without any respiratory events. Postoperative analgesia was provided with IV paracetamol (1.5 g) and surgical site infiltration with 25 mL of 0.25% bupivacaine. The trachea was extubated at the end of surgery, and the patient was observed in the ICU. The patient was successfully discharged from the hospital following an uncomplicated 5-day stay, and allergic medications were documented in the discharge record.

Patients who have experienced an allergic incident must undergo intradermal drug testing to ensure the safety of anesthesia and surgery. Intradermal testing is performed by injecting 0.02 mL of allergen, resulting in an instantaneous wheal of 4.5 to 5.5 mm diameter (Wi). The results are evaluated after 20 minutes by measuring the wheal diameter (W20) and erythema diameter (E20). A positive test is considered if W20 is greater than Wi + 3 mm and E20.[1] However, depending on the allergen used, intradermal testing can result in higher false positive rates. Sevoflurane induction is well-established in adults with poor cardiorespiratory reserve and difficult airways.[2] [3] Patients with multidrug allergies may also benefit from sevoflurane induction, and it can be considered another indication. Allergy to sevoflurane is very rare, and even if there have been rare cases of hypersensitive reactions to sevoflurane, it can be regarded as a safer option when other anesthetic options are limited.[4] Furthermore, in the absence of a neuromuscular blocking medication, sevoflurane can produce ideal intubation conditions.[5] Sevoflurane induction and maintenance with a higher MAC may be valid for patients undergoing spinal surgery. However, for patients with cranial pathology and multidrug allergy, a higher concentration of sevoflurane can have a detrimental effect on cerebral physiology.

In conclusion, sevoflurane is a last resort and a considerably safer alternative for a patient with a multi-drug allergy and limited anesthetic options undergoing spinal surgery.

Article published online:
11 March 2026

© 2026. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

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