NICE AND CLEAN BUT FULL OF WHEALS: ANAPHYLAXIS FROM AN UNEXPECTED SOURCE

Abstract

Introduction Perioperative anaphylaxis (PA) ranges from 1/2000 to 1/20,000 procedures. Povidone-iodine is an antiseptic, excipient, food additive, and is present in skin/hair products. Case description 68-year-old male with a past medical history of cirrhosis secondary to hepatitis C, hepatocellular carcinoma (HCC), aortic stenosis status post transcatheter aortic valve replacement (TAVR), and chronic kidney disease presented with multiple episodes of suspected hypersensitivity reactions. He developed hypotension during radiofrequency ablation of HCC. He received Fentanyl, Etomidate, Succinylcholine, Cisatracurium, Cefazolin, and an unknown antiseptic. Management of this episode is unknown. During TAVR he developed hypotension, bronchoconstriction with increased PEEP and ACLS with chest compressions for 5 minutes. He received Cefazolin, Fentanyl, Propofol, Rocuronium, and radiocontrast media. The antiseptic used is unknown. He has since had radiocontrast without adverse reactions. Tryptase level was 67 ng/mL (baseline 7.1). He was treated with histamine blockers, systemic corticosteroids, and Epinephrine. Generalized pruritus and urticaria of the face and back developed after placement of a peripherally inserted central catheter. The antiseptic used is unknown. He also developed hives with cold exposure. The temperature of the operating room with the above procedures was unavailable. He underwent a complete perioperative hypersensitivity evaluation. Skin prick testing was only positive to Povidone-iodine which was suspected to be one of the antiseptics used (Figure 1). Recommendations were to avoid this antiseptic and limit cold exposure. The patient subsequently underwent orthotopic liver transplant without PA. Chlorhexidine was used as an antiseptic. Discussion Perioperative anaphylaxis (PA) ranges from 1/2000 to 1/20,000 procedures. Povidone-iodine is an antiseptic, excipient, food additive, and is present in skin/hair products. 68-year-old male with a past medical history of cirrhosis secondary to hepatitis C, hepatocellular carcinoma (HCC), aortic stenosis status post transcatheter aortic valve replacement (TAVR), and chronic kidney disease presented with multiple episodes of suspected hypersensitivity reactions. He developed hypotension during radiofrequency ablation of HCC. He received Fentanyl, Etomidate, Succinylcholine, Cisatracurium, Cefazolin, and an unknown antiseptic. Management of this episode is unknown. During TAVR he developed hypotension, bronchoconstriction with increased PEEP and ACLS with chest compressions for 5 minutes. He received Cefazolin, Fentanyl, Propofol, Rocuronium, and radiocontrast media. The antiseptic used is unknown. He has since had radiocontrast without adverse reactions. Tryptase level was 67 ng/mL (baseline 7.1). He was treated with histamine blockers, systemic corticosteroids, and Epinephrine. Generalized pruritus and urticaria of the face and back developed after placement of a peripherally inserted central catheter. The antiseptic used is unknown. He also developed hives with cold exposure. The temperature of the operating room with the above procedures was unavailable. He underwent a complete perioperative hypersensitivity evaluation. Skin prick testing was only positive to Povidone-iodine which was suspected to be one of the antiseptics used (Figure 1). Recommendations were to avoid this antiseptic and limit cold exposure. The patient subsequently underwent orthotopic liver transplant without PA. Chlorhexidine was used as an antiseptic.