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Dr. wasfi A.K. Ali ..chief
of anesth. Dept. tikrit teach.HospTikrit
Iraq
1998
--2004
Abstract
Chlohexidine
solution used as a scolicidal agent caused
an
abnormal strange
effect
( generalized
arteriolar vaso spasm ) This effect
is
considered
to
be an idiosyncrasy to chlohexidine or it is part of its action when
absorption occurs, whatever the cause , Immediate antishock measures
done
with antishock treatment and vasodilaters including papaverine , low
dose dopamine , steroids ,and antihistamines . After 5 hours the
torniquet like action disappeared completely ,radial and femoral
pulses were palpable again with good urine out put ,the patient then
referred to the general ward and then discharged well, so we
recommend to substitute Chlohexidine by other scolicidal agents to
whom the surgeons and anesthetists are more familiar with them
·
Introduction
·
A
20 years old male of 65 kg B.WT. was admitted to tikrit teach. Hosp.
for hydatid cyst excision in the liver ,ultrasound was done with
other general investigation , revealed
Hb%
13 gm / 100 ml ,B urea 42mg/dl, GUE: no abnormality
,
serum
ca ++ 8.6 mg/dl ,SGOT: 31 I.U
SGPT:
29I.U ,TSB=0.8 mg/dl , blood also was prepared
·
Procedure
·
Operation
was started by GA including ketamine 100mg I.V ,suxamethonium
HCL 100mg i.v
,cuffed endotracheal intubation, IPPV,O2 100% ,pancuronium
6mg BP 120/80 ,pulse 90/min , no signes of hypersensitivity
to any anesthetic drug ,but when chlohexidine 5% solution was
injected inside the
cyst suddenly we noticed absence of the radial pulse , the color of
the patient started
to change to dusky ,dark, cyanosed ,( ischemic changes and
color as when we add a tourniquet
to a limb ) Aggravation of this condition
occurred ,that the brachial and popliteal pulses disappeared
also .The pink congested color of the face started to change to dark
red then
cyanosed .At the moment of disappearance of the radial pulse the
patient was considered to be in an anaphylactic shock ,although no
bronchospasm associated with this reaction .The patient was given
hydrocortison 800mg but no improvement , the condition was
aggravated more the ischemia
was explained as : due to arteriolar vasospasm
in the small and medium sized arteries as an idiosyncrasy
to chlorhexidine
, so papaverine SC and IM 20mg was given ,lignocain 100mgIV
,sod.bicarbonate40mmol IV.,lasix20mg,IV.,mannitol 200cc 20% ,calcium
gluconate 10% 10cc ,heparin 10000 IU., .The operation continued,
removal of the cyst done , and closure done, antidote was given (neostigmine
2.5 mg +atropine
1mg IV.)spontaneous breathing started ,good muscle power
,good tidal volume blinking ,weak reflexes ,the
patient was referred to ICU .on ventilator
( IDV mode :intermittent demand ventilation )
·
The
patient looked to be edematous because of no urine out put and
because of over hydration due to antishok measures, so dopamine
infusion (low dose 3-5μgm/kg/min)started
with antishock drugs like steroids, antihistamines ,after 2
hours the patient retained his consciousness ,good
reflexes powerful cough ,extubation done ,radial pulse still
very weak low
BP urine out put improved
so IV fluid was increased , three hours later the patient
BP started to be increased ,radial pulse is very well
detected BP 100/60 pulse 120/min ,After 2 hours the radial pulse is
strongly positive , good general condition no arteriolar vasospasm
color is pink good capillary refilling ,dopamine infusion
stopped , the patient referred to the general ward after 7 days the
patient discharged to home .
·
Discussion
·
It
is well known that hydrated
fluid can causes anaphylactic reaction but unlike to what
happened to
this patient . anesthetic drugs can cause anaphylactic reaction also
,but in this patient no signs noticed immediately after injection or
even after 15 minutes . idiosyncrasy can happen to any substance or
drug . the strange event in this case is that
there is no urticuria or flushing
or signs of vasodilatation on the contrary there is
vasoconstriction ,also there is no bronchospasm ,the experience with
chlorhexidine as a scolicidal agent is little ,this agent when it
was injected ,we noticed this abnormal reaction which is unusual,
never seen before ,it is a tourniquet like action .allot of drugs
has been given ,of antishock
effect , vasodilaters as papaverine and lignocaine .After
papaverine there was some redness on the capillary level and small
arterioles , but the bigger arteries as the radial still not
improved , dopamine was noticed to improve the renal function and
helped to increase the amount of I.V fluids , the steroids and
antihistamines not improved the situation within two hours
There
is a possibility also that the condition
could be self
limiting , however the measures have been used as pulmonary
ventilation and drug
therapy all shared to improve the out come which was too bad at the
beginning .Searching through the internet about similar reactions
revealed the
following : 1- chlorhexidine
rarely lead to anaphylactic reaction 2- chlorhexidine caused
anaphylactic shock during TURP 3- life threatening reaction
associated with mucosal or parenteral exposure
Recommendation
·
It
is better to avoid using drugs or substances not used as routine
scolicidal agents , so chlorhexidine can be substituted by
hypertonic saline which do not carry hazardous side effect
, no similar complication reported in the medline series from
1976 –
97 .no previous use of chlorhexidine as a scolicidal agent as stated
by the (complete drug reference 1996)there is only one case
reported of anaphylactic shock during TURP
Recommendation
·
It
is better to avoid using drugs or substances not used as routine
scolicidal agents , so chlorhexidine can be substituted by
hypertonic saline which do not carry hazardous side effect
, no similar complication reported in the medline series from
1976 –
97 .no previous use of chlorhexidine as a scolicidal agent as stated
by the (complete drug reference 1996)there is only one case
reported of anaphylactic shock during TURP
References
·
Medline
series 1976-
97
·
complete
drug references 1996
·
synopsis
of anesthesia 1984
Internet
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