Chlorhexidine
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Anaphylactic reactions: 5 case reports In a case series, 5 men (who underwent renal transplantation at a hospital in Canada) aged 30–69 years were described, who developed anaphylactic reaction manifesting in the form of hypotension, pulseless electrical activity (PEA) cardiac arrest, narrow complex tachycardia, ST-segment depression, wheezing, increased airway pressures, increase in heart rate, fall in oxygen saturation, bronchospasm, tachycardia, generalised rash or ventricular tachycardia arrest, following administration of chlorhexidine [dosages and times to reactions onsets not stated; not all outcomes stated]. Case 1: The 63-year-old man, who had end-stage renal disease (ESRD) secondary to hypertension and type-II diabetes, presented for renal transplantation in 2008. He had been receiving haemodialysis via an arterio-venous (AV) arm fistula for 6 years. At initial transplant operation, he received pre-treatment with basiliximab, followed by induction of general anaesthesia with midazolam, fentanyl, rocuronium bromide and propofol. Intraoperatively, chlorhexidine-coated central venous catheter [ARROWg+ard Blue PLUS] was placed. Shortly thereafter, he developed profound hypotension, which progressed to a PEA cardiac arrest along with a narrow complex tachycardia and ST-segment depression. Therefore, the transplant procedure was cancelled. Allergy skin tests to rocuronium bromide, cefazolin and latex showed negative results. Also, ImmunoCAP testing for latex-specific IgE was negative. Renal transplantation was again attempted in 2009, without using basiliximab and cefazolin. He received midazolam, propofol, fentanyl and rocuronium bromide for induction of general anaesthesia. During insertion of a chlorhexidine-coated central venous catheter, he developed wheezing along with hypotension, which again progressed to PEA with a narrow complex tachycardia. Subsequent allergy testing to fentanyl, propofol and midazolam was negative. It was noted that the PEA events were allergic in nature; however, a specific allergen was not found. Renal transplantation was again re-scheduled in 2011, without using prior agents. General anaesthesia was induced with thiopental sodium, atracurium-besilate [cis-atracurium] and remifentanil, followed by insertion of chlorhexidine-coated central venous catheter. Approximately 5-10 minutes after catheter insertion, he developed increased airway pressures, followed by hypotension and then PEA/ventricular tachycardia arrest. Serum tryptase was found to be elevated 40 min after the cardiac arrest. Based on the observations that the reactions developed temporally after insertion of chlorhexidine-coated central venous catheter, he was recalled for allergy evaluation in 2015. He underwent test for allergy to basiliximab and chlorhexidine, and he showed a positive skin test result to chlorhexidine only. The finding was confirmed by ImmunoCAP assay for chlorhexidine-specific IgEs. The timings of the multiple PEA arrests after chlorhexidine-coated central venous catheter insertion and test re
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