CHLORHEXIDINE: AN INCREASINGLY RECOGNIZED CAUSE OF PERI-OPERATIVE ANAPHYLAXIS

Introduction Chlorhexidine is an antiseptic and disinfectant that has been increasingly used in medical care such as central venous lines, urinary catheters, and surgical skin preparations. It is also used in over-the-counter products such as mouthwash and cosmetics. A Pubmed search from 1994-2013 showed 65 case reports of chlorhexidine anaphylaxis. True incidence is likely to be underestimated as it is often overlooked as a causative factor. Case Description A 63 yo male with PMH of recent prostate cancer diagnosis presented for radical prostatectomy. An hour into his procedure he developed sustained hypotension which responded well to multiple rounds of epinephrine. His peri-operative tryptase was 48 ng/ml. His initial skin testing to lidocaine, rocuronium, cis-atrocurium, and propofol were negative. During his second tier of testing, he was negative to ketamine and fentanyl. The decision had been made to add on chlorhexidine. He was positive with the skin prick test. A week later he successfully tolerated a repeat prostrate surgery using a chlorhexidine alternative. Discussion The reaction is thought to be slower than with other perioperative agents. The reaction tends to occur more frequently in men with a mean age presentation of 58. Its presentation is often very difficult to treat requiring large doses of epinephrine. Chlorhexidine has historically been underestimated as cause of peri-operative anaphylaxis. In part it is due to limited recognition of its increasing trigger of anaphylaxis but also due to the slower onset of reaction. Chlorhexidine should be considered more regularly in peri-operative anaphylaxis testing.