Intraoperative anaphylaxis associated with bacitracin irrigation

Abstract

Three cases of severe anaphylactic reactions associated with prophylactic bacitracin irrigation during cardiac procedures are describe. In all three cases, bacitracin irrigation was concentrated at 50,000 units per 10 mL and applied directly to the pacemaker pocket. The first case described involved an 88-year-old woman undergoing pacemaker insertion to correct bradycardia. Within 10 minutes of bacitracin irrigation, she lost consciousness and developed apnea, diffuse erythema, and hypotension. In the second case, a 69-year-old man receiving a cardiac resynchronization defibrillator implant developed apnea, hypotension, decreased pulse, erythema of the extremities, and a maculopapular rash within 15 minutes of bacitracin administration. The third case involved an 83-year-old woman undergoing a dual pacemaker battery change; she became agitated and was noted to have hypotension, anxiety, and other symptoms 8 minutes after bacitracin irrigation. Two of the three cases involved apnea and loss of consciousness, and all three patients developed erythema or rash. Application of the adverse drug reaction probability scale developed by Naranjo et al. yielded a score of 3 (indicating a possible adverse reaction to bacitracin) in all three cases. As in other published reports of anaphylactic reactions associated with bacitracin irrigation, development of hypotension within 15 minutes of bacitracin administration was the first sign of an adverse reaction in these cases. Three patients developed severe adverse reactions after prophylactic bacitracin irrigation, two during pacemaker insertions and one during a cardiac resynchronization defibrillator implantation.