To the Editor:-We read with interest a case report by Oda et al., [1]which appeared in a recent issue of Anesthesiology. We also encountered a patient, a 28-year-old man, in whom anaphylactic shock developed twice during anesthesia. He was scheduled to undergo surgery for traumatic brachial nerve palsy. Medical history was limited to allergic rhinitis. Atropine, hydroxyzine, and cefozopran hydrochloride were administered 1 h before the anesthesia. The induction of anesthesia and tracheal intubation was performed uneventfully using thiopental, fentanyl, and vercuronium, and maintained with nitric oxide (NO), oxygen (O2) and isoflurane. A few minutes after the insertion of a central venous catheter impregnated with chlorhexidine and silver sulfadiazine (Arrow gard (+) Blue, Arrow International Inc., Reading, PA), we noticed hypotension (from 115/45 mmHg to 45/28 mmHg), tachycardia (85 beats/min to 125 beats/min), fall of pulse oximetry (SpO2)(from 98% to 79%) and end-tidal pressure of carbon dioxide (PETCO2)(from 35 to 6 mmHg), and skin erythema in his upper body. During resuscitation, his carotid artery pulse was palpable. With administration of ephedrine, lactated Ringer's solution and adrenaline, blood pressure was restored to 118/40 mmHg in 1 h. The surgery was postponed. The central venous catheter was withdrawn the next afternoon. Lymphocyte transformation test was performed for cefozopran hydrochloride, vecuronium, and thiopental. Only cefozopran hydrochloride appeared to be strong-positive (+++).
Four weeks later, his second surgery was scheduled. An arterial line was placed after lidocaine infiltrated locally. Induction of anesthesia and tracheal intubation were performed using midazolam, buprenorphine, ketamine, and vecuronium. Soon after the insertion of a chlorhexidine- and silver sulfadiazine-impregnated catheter (Arrow gard+Blue), blood pressure decreased suddenly (Figure 1). Skin erythema with edema was manifest, and there was no arterial pulse wave evaluated, although a carotid artery pulse was palpable. Heart rate increased from 80 to 120 beat/min. Soon after we noticed edema, we removed the central venous catheter and placed another catheter without impregnation using a guide wire. Blood pressure became measurable within 30 min after the patient received 3,000 ml lactated Ringer's solution and adrenaline, 200 [micro sign]g.
Figure 1. Hemodynamic changes at the second episode 1: arterial line under local anesthesia, 2: anesthesia start, 3: tracheal intubation and 4: insertion of CVP catheter
Figure 1. Hemodynamic changes at the second episode 1: arterial line under local anesthesia, 2: anesthesia start, 3: tracheal intubation and 4: insertion of CVP catheter
Anesthesia was discontinued and the patient regained consciousness with stable cardiorespiratory function. Then, operation was performed. Blood chemical analysis showed a basophil count decreased to zero and plasma histamine levels increased to 80 ng/ml soon after this event. Immunoglobulin E-specific antibody against Latex (Pharmacia & Upjohn, Uppsala, Sweden) was not detected. Six months later, skin testing showed a positive reaction only to 0.01% chlorhexidine (Table 1) and a weak response to 0.001% chlorhexidine.
One yr later, the patient underwent arthrodesis of his shoulder during general anesthesia and had a central venous catheter placed without impregnation (Arrow) uneventfully.
We suspect chlorhexidine was the causative agent for the previous two events. Farber [2]reported that approximately 37% of chlorhexidine from the catheter was released into the blood on the first day of insertion (this level is at most 40 [micro sign]g/ml) and postulated that this blood level could not sensitize the patient. Because chlorhexidine is contained in various pharmaceutical products, it is possible that anaphylactic reactions could occur in such a sensitized patient. Although we know catheter-related anaphylactic reaction is very rare, [3]we should be reminded of the possibility of anaphylactic reactions during and after insertion of chlorhexidine-impregnated catheters in the operation room, the intensive care unit, and the emergency room.
Etsuji Terazawa, M.D.
Hiroyuki Shimonaka, M.D.
Kiyoshi Nagase, M.D.
Tatsuhiko Masue, M.D.
Staff Anesthesiologists
Shuji Dohi, M.D.
Professor and Chairman; Department of Anesthesiology and Critical Care Medicine; Gifu University School of Medicine; Tsukasamachi, Gifu, Japan;shu_dohi@cc.gifu-u.ac.jp
(Accepted for publication July 10, 1998.)
