Chlorhexidine
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Aseptic subcutaneous tissue inflammation following inadvertent entry of the drug: case report A 26-year-old woman developed aseptic subcutaneous tissue inflammation following inadvertent entry of chlorhexidine, which was used as an antiseptic solution. The G1P0 woman was admitted in active labour following an uneventful pregnancy. She required epidural anaesthesia (EA) for labour pain. Antiseptic cleaning was performed using a chlorhexidine stick [dosage not stated] and the target area was draped aseptically. After allowing an adequate time to dry, the skin and the underlying subcutaneous tissues at the target needle-entry site paramedian to the L3–L4 intervertebral space were infiltrated with 2% lidocaine. Then, an 18-gauge epidural set was inserted in the epidural space to locate it using the loss of resistance to saline technique. The epidural space was uneventfully identified and an epidural catheter inserted and retained in the epidural space. After a negative result by the test dose, a loading dose of levobupivacaine was administered. Subsequently, an epidural infusion was started based on institutional protocol. She had instant pain relief and remained comfortable throughout. A caesarean section was performed. A sterile dressing was applied. She received standard unspecified antibacterial [antibiotic] prophylaxis and postoperative care. She had an uneventful recovery and was discharged after 2 days. On post-operative day 7, she returned (readmitted) with new-onset atypical back pain without a clear dermatomal pattern. She had exquisite pain at the needle-entry site, which radiated to the mid- thoracic region, contrary to a downward radiation, without any radicular involvement. She did not have any fever, headache or signs of meningism, but had slight erythema at the needle-entry site. Her CRP and WBC count was normal. A neurological examination was unremarkable. The woman received conservative treatment with unspecified analgesics, antibacterials and physiotherapy. The persistent sever pain interfered with childcare. MRI showed inflammation of the subcutaneous tissues overlying the L1–5 vertebrae. There was no evidence of haematoma or drainable fluid. Hence, no further intervention was provided other than continuing the conservative management. Her pain reduced steadily and she recovered fully after 5 days. A diagnosis of aseptic subcutaneous tissue inflammation following inadvertent entry of chlorhexidine was made. Author comment: "After multidisciplinary discussions, we suspected aseptic inflammation caused by inadvertent entry of cytotoxic chlorhexidine as the most probable diagnosis". Bhakta P, et al. Aseptic subcutaneous inflammation presenting as late onset back pain after uneventful epidural anesthesia. Korean Journal of Anesthesiology 72: 508-509, No. 5, Oct 2019. Available from: URL: http://doi.org/10.4097/kja.19187 803436170 Ireland
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Editorial comment: Details of this case report have previously been published [see Reactions 1724 p107; 803350719].
0114-9954/19/1781-0001/$14.95 Adis © 2019
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