Table 2A: Case List.

Case # Demographics Anesthetic evaluation or pertinent history Surgical and perioperative treatments
Case 1 74-year-old male, retired professional healthcare worker. Patient reported > 30 anaphylactic reactions between 2015-2018. Reactions included medications with hidden ingredients containing mammalian byproducts; cross-contaminated foods. General anesthesia for elective major cervical spine surgery: Anterior cervical 4-7 decompression, corpectomy, instrumented fusion with cages and allograft; plate and screws. Outsourcing food and meals from home.
Case 2 59-year-old female Reported immediate anaphylaxis to the cancer drug cetuximab. Delayed allergy to beef and porcine containing products; medications containing maltose. Hydroxychloroquine induced Steven-Johnson syndrome. General anesthesia for elective gynecologic surgery: Hysteroscopy, polypectomy.
Case 3 84-year-old female Reported positive formal allergy testing for alpha-gal allergy. Reactions included pruritis and urticaria after consuming beef on several occasions. Neuraxial anesthesia for elective total knee arthroplasty and received preoperative triggering agents inadvertently via ERAS protocol.
Case 4 37-year-old female Pertinent medical history included comorbidities: Cushing's disease, diabetes insipidus. Alpha-gal allergy was known by patient but not updated in EHR. Patient inadvertently received celecoxib and gabapentin as part of an ERAS protocol before her alpha gal allergy was realized. General anesthesia for elective total laparoscopic hysterectomy and cystoscopy. The pharmacy packaging for the drug did not have an NDC number. The drug lot number proved to be insufficient for providers to determine the manufacturer in a timely fashion. Subsequently, preemptive steroids and antihistamines were administered perioperatively.
Case 5 60-year-old female Patient at high risk for recurrent DVT. Reviewed the allergist's consult in 2018 documenting 50% decrease in both alpha-gal and IgE levels compared to previous titers from 2017. General anesthesia for emergent laparoscopic cholecystectomy with known alpha-gal allergy. After considering benefits versus risks the patient received a potential triggering agent enoxaparin for DVT prophylaxis prior to surgery and continued post-operatively during hospitalization.
Case 6 80-year-old female The patient reported an allergy to beef and pork in the PACU. The allergy was unclassified as alpha-gal allergy prior to surgery.
Other allergies including anaphylaxis, hives or swelling included: dextromethorphan, hydrocodone, oxycodone, amoxicillin, levaquin.
General anesthesia for elective colpopexy, extraperitoneal sling for stress incontinence, repair of rectocele, cystoscopy. Patient did not qualify for an ERAS protocol, therefore common triggering agents were not introduced. Intraoperative management included dexamethasone. In the PACU, the patient developed anaphylaxis including bronchospasm, diffuse rash over the chest and neck, and perioral swelling immediately after receiving IV albumin for fluid management and correction of hypotension with intraoperative EBL 125 milliliters. Symptoms improved after diphenhydramine IV.

ERAS: Enhanced Recovery After Surgery; HER: Electronic Healthcare Records; NDC: National Drug Code; DVT: Deep Venous Thrombosis; PACU: Postoperative Anesthesia Care Unit; IV: Intravenous.