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CASE REPORTS

Bacitracin Irrigation: A Cause Of Anaphylaxis in the Operating Room

Mark Blas, MD^*, Kurt S. Briesacher, MD^*, and Emilio B. Lobato, MD^*,

*Department of Anesthesiology, University of Florida College of Medicine; and Anesthesiology Service, Veterans Affairs Medical Center, Gainesville, Florida

Address correspondence to Mark L. Blas, MD, Department of Anesthesiology, University of Florida College of Medicine, Box 100254 JHMHSC, Gainesville, FL 32610-0254.

	Abstract

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Implications: We report a unique case of acute anaphylaxis after mediastinal irrigation with a dilute bacitracin solution.

	Introduction

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Although hypotension is not an uncommon event in the course of general anesthesia, intraoperative hypotension caused by anaphylaxis has a reported incidence of only 0.004%–0.02% (1). Most commonly, intraoperative anaphylaxis occurs after the IV administration of medications, although topically applied substances must also be considered (e.g., latex, ointments, solutions, etc.). Of particular significance, there have been numerous reports of allergic reactions to topical bacitracin ointment, but only two cases of intraoperative anaphylaxis caused by bacitracin irrigation have been reported in the literature (2,3). We report an interesting case of anaphylaxis after mediastinal irrigation with a bacitracin solution.

	Case Report

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A 65-yr-old man presented for elective sternal debridement and rewiring. He had a history of mitral valve replacement with a Bjork-Shiley prosthetic valve implanted 1 yr earlier for severe mitral regurgitation. Other medical problems included hypertension, diabetes mellitus, and hiatal hernia. He had an allergy to penicillin, which produced a systemic rash, nausea, and vomiting.

Preoperative medications included metoprolol, ranitidine, and warfarin. Preoperative evaluation revealed no history of anesthetic complications. On physical examination, the patient had no evidence of congestive heart failure. Heart sounds were considered normal. Chest radiograph revealed no acute disease, and the electrocardiogram was normal. A preoperative echocardiogram revealed an ejection fraction of 55%, no segmental wall motion abnormalities, and a normally functioning Bjork-Shiley mitral valve. A prophylactic vancomycin infusion (1 g) was initiated in the preoperative holding area and administered for a duration of 1 h. Anesthesia was induced by using thiopental (4 mg/kg), succinylcholine (1 mg/kg), and fentanyl (3 µg/kg) and maintained with fentanyl, vecuronium, and isoflurane in an air/oxygen mixture.

Surgical findings consisted of a localized pocket of serous fluid (approximately 20 mL), and the entire mediastinum was subsequently washed with bacitracin irrigation (approximately 25 U/mL). Immediately after the placement of the first sternal wire (approximately 40 min after the induction of anesthesia and 10 min after wound irrigation), the arterial blood pressure decreased precipitously from 120/70 to 65/40 mm Hg. The mediastinum was inspected and showed no evidence of hemorrhage or cardiac injury. The electrocardiogram showed an increased rate from 70 to 80 bpm with no S-T segment changes. IV fluid resuscitation was begun while breath and cardiac sounds were auscultated. The anesthetics were discontinued, and 100% oxygen was given. The mechanical sounds from the prosthetic valve were unchanged, and breath sounds were equal bilaterally. The patient was placed in steep Trendelenburg position, and ephedrine (total dose 50 mg IV) was given incrementally with minimal response. The end-tidal CO₂ decreased from 35 to 31 mmHg, which coincided with the onset of hypotension. Esophageal temperature was unchanged at 36.5°C. Arterial blood pressure began to improve after several small IV boluses of epinephrine (4 µg/bolus) and a total of 2 L of fluid given IV

A transesophageal echocardiography (TEE) probe was placed to further evaluate cardiac function. There were no segmental wall motion abnormalities as viewed in the gastric short-axis, midpapillary view. The prosthetic mitral valve appeared competent, with normal bileaflet motion. There was no significant mitral regurgitation and no signs of cardiac tamponade. The left-ventricular end-diastolic area was normal, but the end-systolic area was significantly reduced, compatible with a decrease in afterload. At this time, it was also noted that the patient’s face and upper extremities were flushed red. As a result of the TEE findings and the patient’s flushed color, the diagnosis of an anaphylactoid reaction was made.

IV fluid resuscitation and boluses of epinephrine were given in addition to diphenhydramine (50 mg), hydrocortisone (100 mg), and famotidine (20 mg). After approximately 20 min from onset of flushing, arterial blood pressure was 120/75 mm Hg, and the cutaneous flushing had resolved. A small-dose epinephrine infusion (0.005 µg · kg^-1 · min^-1) was rapidly titrated and discontinued. Examination of the anesthesia back table revealed no ampules or bottles of medication suspicious for a drug error.

The remainder of the surgery was uneventful. Breath sounds were clear to positive pressure and spontaneous ventilation at the end of surgery. An endotracheal tube cuff leak was noted with balloon deflation. The patient awoke at the end of surgery, was tracheally extubated, and was transferred to the recovery room.

Before discharge from the recovery room, the patient’s history of allergy was again questioned. It was discovered that he had, in fact, several years earlier developed a rash after using an over-the-counter antibiotic ointment, Neosporin^® (Burroughs Wellcome, Research Triangle Park, NC; a triple antibiotic ointment consisting of polymixin B, bacitracin, and neomycin). No other complications had developed at that time, and the patient discontinued further use. He had forgotten the incident when initially questioned preoperatively. Based on the patient’s previous adverse reaction and the temporal association to bacitracin exposure in the operating room, the diagnosis of a bacitracin allergy was made. The patient was instructed to avoid further bacitracin exposure in the future and was scheduled to receive a medical alert bracelet. No further testing was performed.

	Discussion

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We report an intraoperative case of anaphylactic shock, its diagnosis, and treatment. This case involved the sudden onset of hypotension after mediastinal irrigation with a bacitracin irrigation solution. Other causes of hypotension were eliminated by examination of the surgical field, review of the medications administered, TEE examination of the heart, and a direct examination of the patient. TEE was extremely helpful in the initial diagnosis, as it helped eliminate a mechanical (prosthetic valve dysfunction), traumatic (surgical trauma to the heart or great vessels), or ischemic source for this patient’s hypotension. This is the first report of an anaphylactic reaction to bacitracin irrigation involving a thoracic surgical procedure.

A review of the medical literature reveals that intraoperative anaphylaxis has a reported incidence of one case per 5000–25,000 anesthetics with a 3.4% mortality (1). It can be precipitated by a number of different sources in the operating room, including a variety of medications, blood transfusions, and implantable prosthetic devices. Intraoperative anaphylaxis is usually caused by the IV administration of medications; more than 90% of the reactions evoked by IV drugs occur within three minutes of administration. The most common life-threatening manifestation seen in the anesthetized patient is circulatory collapse caused by peripheral vasodilatation. Common cardiovascular signs include hypotension, tachycardia, dysrhythmias, pulmonary hypertension, and cardiac arrest. Other signs are laryngeal edema, wheezing, decreased pulmonary compliance, urticaria, flushing, periorbital and perioral edema (1), and increased peripheral tissue temperature (4). In some instances, the only manifestation in the anesthetized patient is refractory hypotension (1).

Several reports of anaphylaxis caused by topical bacitracin ointment have been reported (5). Reports of anaphylaxis caused by irrigation with bacitracin solutions are rare (2,3). Bacitracin solutions rapidly produce high serum drug levels during wound irrigation, with peak concentrations exceeding those after IM injection (6). In this case, absorption of bacitracin through the open bone of the sternum, as well as exposed vessels, may have led to the development of high serum drug levels, initiating the anaphylactic response. Of importance, it has been suggested in the orthopedic literature to avoid repetitive exposures to bacitracin irrigation because of the risk of anaphylaxis. Unfortunately, other alternatives, such as saline irrigation, are not as effective at reducing infection (7).

This patient’s previous exposure to Neosporin^® ointment with development of a localized rash suggested his bacitracin sensitivity. Knowledge of this previous reaction may have prevented subsequent exposure during this procedure. (A chart review indicated that he had not received mediastinal bacitracin irrigation at the time of his first valvular surgery one year before this event).

To confirm the occurrence of an anaphylactic reaction, diagnostic tests can be performed, including detection of an increased plasma tryptase level (8) or radioimmunoassay of the patient’s serum to search for antibodies against the inciting medication (9). We did not pursue further workup because of the relevant history identified after the surgery with respect to the patient’s previous bacitracin exposure and reaction. Certainly, other medications or latex could have caused this reaction, but again, because of the temporal relation to the operative bacitracin exposure and history, no further workup was performed.

This case highlights the importance of considering preoperative exposure and adverse reactions to over-the-counter medications in procedures in which further exposure could be anticipated. Although most causes of intraoperative anaphylaxis are the result of IV administered medications, there are other causes.

	References

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1. Levy JH. The allergic response. In: Barash PG, ed. Clinical anesthesia. 3rd ed. Philadelphia: Lippincott-Raven, 1997: 1205–17.
2. Netland PA, Baumgartner JE, Andrews BT. Intraoperative anaphylaxis after irrigation with bacitracin: case report. Neurosurgery 1987; 21: 927–8.[Medline]
3. Sprung J, Schedewie HK, Kampine JP. Intraoperative anaphylactic shock after bacitracin irrigation. Anesth Analg 1990; 71: 430–3.[Free Full Text]
4. Kotani N, Kushikata T, Matsukawa T, et al. A rapid increase in foot tissue temperature predicts cardiovascular collapse during anaphylactic and anaphylactoid reactions. Anesthesiology 1997; 87: 559–68.[Web of Science][Medline]
5. Fisher AA. Adverse reactions to bacitracin, polymyxin, and gentamycin sulfate. Cutis 1983; 32: 510–2.[Medline]
6. Ericsson CD, Duke JH Jr, Pickering LK, Quadri SM. Systemic absorption of bacitracin after peritoneal lavage. Am J Surg 1979; 137: 65–7.[Medline]
7. Dirschl DR, Wilson FC. Topical antibiotic irrigation in the prophylaxis of operative wound infections in orthopedic surgery. Orthop Clin North Am 1991; 22: 419–26.[Web of Science][Medline]
8. Renz CL, Laroche D, Thurn JD, et al. Tryptase levels are not increased during vancomycin-induced anaphylactoid reactions. Anesthesiology 1998; 89: 620–5.[Web of Science][Medline]
9. Gueant JL, Aimone-Gastin I, Namour F, et al. Diagnosis and pathogenesis of the anaphylactic and anaphylactoid reactions to anaesthetics. Clin Exp Allerg 1998; 28 (Suppl 4): 65–70.

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