chlorhexidine-gluconate--lidocaine-drug-combination and Anaphylaxis

A 70-year-old man with left lower limb critical ischaemia was admitted to our vascular unit for a femoral-popliteal bypass. He had experienced a skin reaction to chlorhexidine 6 months previously during an angioplasty procedure. After intubation, once in the operating theatre, the patient had a urinary catheter inserted using Instillagel. Around 30 min later the patient had a full-blown anaphylactic reaction that required aggressive medical management and the abandoning of surgery. Postoperative allergy testing confirmed that the suspected primary trigger for the anaphylaxis was indeed chlorhexidine, which was present in Instillagel. The patient was also found to have allergies to atracurium and teicoplanin, which had been given on induction. This case report highlights the importance of recognising that Instillagel contains chlorhexidine, and that indeed intraurethral use during routine urinary catheterisation can be a cause of life-threatening anaphylaxis.

Topics: Aged; Anaphylaxis; Anti-Infective Agents, Local; Chlorhexidine; Diagnosis, Differential; Drug Combinations; Femoral Artery; Humans; Intraoperative Complications; Ischemia; Lidocaine; Lower Extremity; Male; Urinary Catheterization; Vascular Surgical Procedures

Instillagel(®) (CliniMed, High Wycombe, UK) is commonly used in urethral catheterisation and to facilitate the passage of instruments into the bladder in urological practice. Its active ingredients include 0.25% chlorhexidine, 2% lidocaine, 0.06% methyl hydroxybenzoate and 0.025% propyl hydroxybenzoate. We discuss the case of an 84-year-old man who received intraurethral Instillagel(®) prior to laser ablation of a recurrent transitional cell carcinoma of the bladder, resulting in anaphylaxis. Subsequent investigation confirmed allergy to chlorhexidine. Although there are previous reports in the literature, this is the first report of intraurethral chlorhexidine resulting in anaphylaxis in a patient who had had repeated, uneventful previous exposures. As such, this case illustrates the phenomenon of chlorhexidine sensitisation and that previous uneventful exposures do not exclude the diagnosis of anaphylaxis in the context of sudden, unexpected deterioration.

Topics: Aged, 80 and over; Anaphylaxis; Anti-Infective Agents, Local; Chlorhexidine; Cystoscopy; Drug Combinations; Drug Hypersensitivity; Humans; Lidocaine; Male; Urinary Catheterization

Chlorhexidine gluconate is a chemical antiseptic that is effective against Gram positive and negative bacteria and on certain viruses and fungi. A bacteriocidal and bacteriostatic agent, this cationic drug is absorbed on to negatively charged cell surfaces of organisms, disrupting the cell membrane, which results in increased permeability. Its use is mainly topical as a surgical hand antisepsis, site preparation/cleansing and for pre-genitourinary procedures such as urethral catheterisation. Like any drug, caution should be employed with its use as hypersensitivity reactions are being documented increasingly in the medical literature. In the following case, we present a patient who was catheterised with the chlorhexidine containing Instillagel(®) (CliniMed, High Wycombe, UK), prior to undergoing elective orthopaedic surgery.

Topics: Aged; Anaphylaxis; Anti-Infective Agents, Local; Arthroplasty, Replacement, Hip; Chlorhexidine; Drug Combinations; Drug Eruptions; Humans; Hypotension; Lidocaine; Male; Urinary Catheterization