San Francisco, USA
EditorSentinel lymph node biopsy (SLNB) is a minimally invasive technique, which has been introduced into breast surgery. It has the potential to limit the need for full axillary clearance in patients with positive axillary nodes.1 The technique uses isosulphan blue dye (Hirsch Industries Inc., Richmond, VA, USA), a patent blue dye derivative, either alone or in combination with a radio colloid, to aid the detection of malignant metastasis to sentinel nodes.2 We recently treated a 50-yr-old female with breast cancer who developed a severe reaction to isosulphan blue. Anaesthetists should be made aware of the high incidence of adverse reactions to this substance.
The patient was scheduled for left lumpectomy and left axillary SLNB with localization using isosulphan blue dye and technetium-99 sulphur colloid, in an outpatient setting. After radio colloid injection and lymphoscintography, she was transferred to the operating room facility and anaesthesia was induced using fentanyl 150 mg, propofol 120 mg and rocuronium 40 mg. Uneventful anaesthesia continued for 50 min during the initial stages of the operation. After 50 min, the surgeon injected isosulphan blue 3 ml subcutaneously around the tumour. Approximately 30 min after this injection, the patients systolic arterial pressure fell abruptly from 104 to 70 mm Hg. Over the following few minutes, repeated ephedrine 10 mg and phenylephrine 200 mg boluses were administered intravenously. Her systolic arterial pressure further decreased to 64 mm Hg, and then to 52 mm Hg. SpO2 declined marginally from 99100% to 9596%, as is expected with isosulphan blue. End tidal carbon dioxide concentration remained unchanged. No bronchospasm, rash or urticaria were observed.
Anaesthesia was reduced to the minimum necessary consistent with amnesia, i.v. epinephrine 100 µg was given and the patients arterial pressure increased transiently. Resuscitation continued with i.v. fluids and epinephrine in repeated 100300 µg i.v. boluses. During the next 30 min, 56 litres of i.v. fluid and epinephrine 2 mg were given. A right radial artery cannula was placed for continuous monitoring of arterial pressure. After 30 min, frequent repeated epinephrine boluses were still required to maintain cardiovascular stability. The patients right internal jugular vein was cannulated, hydrocortisone 100 mg and diphenhydramine 50 mg were administered, and a continuous infusion of epinephrine 400 µg1 h1 was established. Her systolic arterial pressure stabilized at 100110 mm Hg. Blood was obtained for measurement of serum mast cell tryptase concentration, routine bloods tests, clotting and arterial blood gases. The decision was taken to continue with the lumpectomy to remove excess isosulphan blue and minimize the possibility of a biphasic anaphylactic reaction.2 3 Concomitant planned gynaecological surgery was cancelled.
After surgery, the patient was admitted to the intensive care unit. She continued to require epinephrine to maintain cardiovascular stability. She also developed orofacial oedema. But after 12 h, the oedema resolved, the epinephrine infusion was weaned and the tracheal tube was removed. She was discharged home 3 days after surgery with no residual effects.
Sentinel lymph node biopsy has the potential to become a common treatment for patients with breast cancer because it allows effective axillary node clearance without the associated co-morbidity. Isosulphan blue is widely used for SLNB and anaphylaxis precipitated by its use is sufficiently common to be of clinical concern. The manufacturer of the dye suggests a 1.5% incidence of adverse reactions, all of them allergic.4 The literature quotes a range of between 0.6 and 2.5%.3 58 When the SLNB technique is introduced into clinical practice, the risks associated with isosulphan blue need careful consideration. For instance, perhaps as part of informed consent, patients should be told of the possible occurrence of life threatening complications. We also question whether it is appropriate to administer isosulphan blue in the day case settingcertainly, adequate facilities to care for the patient during and after surgery should be available. Anaesthetic personnel should be aware of these potential problems with isosulphan blue and be equipped to deal with them.
T. B. Stefanutto
W. A. Shapiro
P. M. C. Wright
San Francisco
USA
References
1 Darzi A, Mackay S. Recent advances in minimal access surgery. Br Med J 2002; 324: 314
2 Krag D, Weaver D, Ashikaga T, et al. The sentinel node in breast cancera multicenter validation study. N Engl J Med 1998; 339: 9416
3 Leong SP, Donegan E, Heffernon W, Dean S, Katz JA. Adverse reactions to isosulfan blue during selective sentinel lymph node dissection in melanoma. Ann Surg Oncol 2000; 7: 3616
4 Hirsh Industries Inc. Isosulfan blue 1% aqueous solution (lymphazurin 1%)product monograph. 1983
5 Albo D, Wayne JD, Hunt KK, et al. Anaphylactic reactions to isosulfan blue dye during sentinel lymph node biopsy for breast cancer. Am J Surg 2001; 182: 3938[ISI][Medline]
6 Kuerer HM, Wayne JD, Ross MI. Anaphylaxis during breast cancer lymphatic mapping. Surgery 2001; 129: 11920[Medline]
7 Cimmino VM, Brown AC, Szocik JF, et al. Allergic reactions to isosulfan blue during sentinel node biopsya common event. Surgery 2001; 130: 43942[ISI][Medline]
8 Longnecker SM, Guzzardo MM, Van Voris LP. Life-threatening anaphylaxis following subcutaneous administration of isosulfan blue 1%. Clin Pharm 1985; 4: 21921[ISI][Medline]