Preoperative local anaesthesia allergy testing before LLETZ in patientwith Articane allergy

Category: Colposcopy & Cervical Pathology

Dr Jessica Shortland (FY1), Mr Mohamed Shahin, Dr Nancy Noah - Department of Obstetrics & Gynaecology, University Hospitals of North Midlands, UK

Objectives: To demonstrate how allergy testing can guide the selection of a safe anaesthetic agent in a frail patient with severe Articaine allergy, enabling successful cervical loop excision (LLETZ) under local anaesthesia and avoiding general anaesthesia.

Case presentation: 64F, Referred to colposcopy clinic following an abnormal smear - severe dyskaryosis requiring urgent LLETZ procedure.  Frail with multiple comorbidities including cardiovascular disease, making general anaesthesia high-risk. Severe allergy to Articaine! An amide local anaesthetic (LA)

Allergy Testing & Anaesthetic Strategy:  Referral to a specialist immunology clinic for identification of an alternative LA agents. Mepivacaine selected for use in procedure.

Procedure & Outcome: LLETZ performed under local anaesthesia using Mepivacaine, Performed in an outpatient setting with no sedation, Uncomplicated procedure with no adverse events intra or post-operatively, Patient was safely discharged home on the same day.

Discussion: This case demonstrates the value of preoperative local anaesthetic (LA) allergy testing in enabling safe outpatient management for a frail patient with a known Articaine allergy. Traditional management may have necessitated general anaesthesia (GA), but given the patient's comorbidities, this posed significant risk. Allergy testing identified Mepivacaine and Lidocaine as well-tolerated alternatives, allowing the LLETZ to be performed under local anaesthesia.

This process:  1. Avoided the risks associated with GA in a high-risk patient. 2. Ensured personalised, patient-centred care.  3. Showcased effective multidisciplinary

collaboration between gynaecology, anaesthetics and immunology.

Broader Implications:

•Allergy testing should be considered in any patient with a suspected or confirmed

LA allergy, especially when GA pose significant risks to patient.

•Supports a growing role for tailored outpatient surgical management.

•Highlights the importance of integrating allergy services into perioperative planning.

Supporting Literature: 

1. True allergy to amide local anaesthetics is rare, but allergy testing can identify safe alternatives when history is unclear or high-risk. 

2. NICE recommends referral to specialist allergy services for patients with suspected LA allergy prior to surgery, to guide anaesthetic planning. 

3. National and international guidelines support individualised anaesthesia planning in frail or complex patients to reduce GA-associated risks. 

4. LLETZ is well-tolerated under LA in the majority of cases, making it ideal for outpatient management when GA is contraindicated. 

Learning Points: 

Allergy testing can enable safe use of LA in patients with suspected or confirmed allergy.

Avoidance of GA in frail patients reduces procedural risk.

Multidisciplinary collaboration is essential.

Consider immunology referral where LA allergy history is unclear or clinically significant

This approach can be safely adopted in other surgical specialties where LA is preferred but allergy risk is uncertain.

References:

Bhole MV, Manson AL, Seneviratne SL, Misbah SA. IgE-mediated allergy to local anaesthetics: Separating fact from perception:

A UK perspective. British Journal of Anaesthesia. 2012 Oct;109(4):669. doi:10.1093/bja/aes348

NICE. Drug allergy: diagnosis and management. Clinical guideline [CG183]. 2014. https://www.nice.org.uk/guidance/cg183

NICE. Perioperative care in adults. NICE guideline [NG180]. 2020. https://www.nice.org.uk/guidance/ng180

Royal College of Obstetricians and Gynaecologists. Large loop excision of the transformation zone (LLETZ). RCOG; 2020. Available

from: https://www.rcog.org.uk/for-the-public/browse-our-patient-information/large-loop-excision-of-the-transformation-zone-lletz/