JOURNAL HOME CME HOME THIS MONTH PAST ISSUES ETOC COLLECTIONS AUTHORS REVIEWERS EDITORIAL BOARD FEEDBACK RSS HELP
		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via ISI Web of Science (66) Citing Articles via Google Scholar Google Scholar Articles by Montgomery, L. L. Articles by Borgen, P. I. Search for Related Content PubMed PubMed Citation Articles by Montgomery, L. L. Articles by Borgen, P. I. Related Collections Pharmacology

---

ANESTHETIC PHARMACOLOGY

Isosulfan Blue Dye Reactions During Sentinel Lymph Node Mapping for Breast Cancer

Leslie L. Montgomery, MD^*, Alisa C. Thorne, MD, Kimberly J. Van Zee, MS MD^*, Jane Fey, MPH^*, Alexandra S. Heerdt, MD MPH^*, Mary Gemignani, MD^*, Elisa Port, MD^*, Jeanne Petrek, MD^*, Hiram S. Cody, III, MD^*, and Patrick I. Borgen, MD^*

*Breast Service, Department of Surgery, and Department of Anesthesia, Memorial Sloan-Kettering Cancer Center, New York, New York

Address correspondence and reprint requests to Leslie L. Montgomery, MD, MSKCC-MRI 1026, 1275 York Ave., New York, NY 10021. Address e-mail to montgoml{at}mskcc.org

	Abstract

Top Abstract Introduction Methods Results Discussion References

 
In the United States, identification of the sentinel lymph node (SLN) requires the use of ^99mTc-labeled colloid, 1% isosulfan blue dye, or both to trace the lymphatic drainage of a given neoplasm. We report our experience with adverse reactions to isosulfan blue dye during SLN mapping in breast cancer. A chart review of the breast cancer SLN database was performed; it included 2392 sequential patients who underwent SLN biopsy involving isosulfan blue dye at Memorial Sloan-Kettering Cancer Center from September 12, 1996, to August 17, 2000. Thirty-nine of 2392 patients (1.6%) had a documented allergic reaction during the mapping procedure. Most reactions (69%) produced urticaria, blue hives, a generalized rash, or pruritus. The incidence of hypotensive reactions was 0.5%. Although anaphylaxis after the injection of isosulfan blue dye is rare, this article highlights the need to suspect anaphylaxis when hemodynamic instability occurs after the injection of this compound. Our experience indicates that bronchospasm and respiratory compromise are unusual and that most patients do not require emergent intubation and can be managed with short-term pressor support. In addition, our data indicate that patients with a sulfa allergy do not display a cross-sensitivity to isosulfan blue dye.

IMPLICATIONS: We report the largest single-institution review of adverse reactions to injection of isosulfan blue dye during sentinel lymph node mapping in breast cancer. Bronchospasm and respiratory compromise are unusual, and most patients can be treated with short-term pressor support. Patients with a sulfa allergy do not display a cross-sensitivity to isosulfan blue dye.

	Introduction

Top Abstract Introduction Methods Results Discussion References

 
Sentinel lymph node (SLN) mapping and biopsy are now routinely used for accurate staging of malignant melanoma and breast cancer. In addition, there is active investigation of the use of SLN mapping in many other tumor types. In the United States, identification of the SLN requires the use of ^99mTc-labeled colloid, 1% isosulfan blue dye, or both to trace the lymphatic drainage of a given neoplasm. Isosulfan blue dye is the only vital dye that the Food and Drug Administration has approved for use in SLN mapping in the United States.

In the future, isosulfan blue dye will probably be given to a wider spectrum of patients as the indications for SLN biopsy broaden and as more physicians throughout this country and the world become familiar with the technique. There is extensive historical experience with vital dyes for lymphangiography, including patent blue dye and its 2,5-disulfonated isomer, isosulfan blue. Allergic and anaphylactic reactions to these dyes have been documented for decades. Despite this experience, many health care professionals are unaware of the incidence and potential severity of an allergic reaction to isosulfan blue dye.

We report our experience with adverse reactions to isosulfan blue dye during SLN mapping in breast cancer. Through a review of our SLN database, we describe the incidence, timing, and severity of these reactions.

	Methods

Top Abstract Introduction Methods Results Discussion References

 
We performed a retrospective chart review of a prospective SLN database to include all patients who underwent SLN biopsy for breast cancer at Memorial Sloan-Kettering Cancer Center (MSKCC) from September 12, 1996, to August 17, 2000. The MSKCC adverse drug reaction reports and quality-assurance incident reports involving isosulfan blue dye during this period were also reviewed.

A total of 2464 SLN mapping procedures were performed during this time. All patients had signed informed consent for the procedure. Fifty patients had bilateral synchronous SLN mapping procedures and were recorded in the SLN database as two distinct mapping procedures. For the purposes of our study, we counted these patients only once, because isosulfan blue dye exposure occurred only once during surgery, even though it involved both breasts. Twenty-two patients were not given isosulfan blue dye. Therefore, the final population examined for isosulfan blue dye reactions comprised 2392 individual patients.

At MSKCC, most patients elect breast-conservation therapy and have the lumpectomy or reexcision and SLN biopsy performed under monitored sedation with local anesthetic. A combination of fentanyl, propofol, midazolam, lidocaine, and/or bupivacaine is routinely used in this setting. If a patient is undergoing a mastectomy or axillary lymph node dissection, general anesthesia is given.

The protocol and technique of SLN mapping and biopsy at MSKCC have been described previously (1). As part of the SLN mapping protocol, isosulfan blue dye (Lymphazurin 1%; Ben Venue Laboratories, Inc., Bedford, OH) is injected intraparenchymally into the breast tissue adjacent to the tumor or biopsy cavity. This injection is given in the operating room just before the surgical procedure.

	Results

Top Abstract Introduction Methods Results Discussion References

 
Thirty-nine of 2392 patients (1.6%) had a documented allergic reaction during the SLN mapping procedure involving isosulfan blue dye. Distinct patterns of reaction were identified on review of the patient charts. A Grade 1 reaction was defined as urticaria, pruritus, blue hives, or a generalized rash. A Grade 2 reaction involved transient hypotension (systolic blood pressure >70) but did not require pressor support. A Grade 3 reaction was defined as hypotension (systolic blood pressure <70) requiring pressor support.

Of the 39 reactive patients in our series, 27 patients (69%) had Grade 1 reactions. Three patients (8%) had Grade 2 reactions, and nine patients (23%) had Grade 3 reactions. Only two patients (one Grade 1 and one Grade 3 reaction) had hypoxia with oxygen saturation <90%, as determined by pulse oximetry (Nellcor Puritan Bennett, Inc., Pleasanton, CA). Only one patient (Grade 1 reaction) had wheezing. There were no deaths.

The time interval between the injection of isosulfan blue dye and the adverse reaction was documented in 35 patients. The mean was 44 min, and the median was 43 min. For Grade 1 reactions, the mean interval was 49 min (median, 46 min; range, 1–205 min); for Grade 2 reactions, the mean was 28 min (range, 5–50 min); and for Grade 3 reactions, the mean interval was 35 min (median, 37 min; range, 5–100 min).

Of the 18 patients with a clearly documented resolution of symptoms, the mean duration was 202 min (median, 143 min; range, 15–600 min). The most severe Grade 3 reaction required 10 h of pressor support. During that time, the patient was alert and communicative. She exhibited no respiratory compromise and at no time required intubation.

The mean volume of dye injected for the total SLN database was 3.9 mL (range, 0.1–10 mL). The mean volume of dye injected into patients who had a blue dye reaction during SLN biopsy was 4.0 mL (range, 2–5 mL). The mean volume of dye injected into patients with a Grade 3 reaction was 3.7 mL (range, 3–5 mL). The difference in injected dye volume between the Reactive and Nonreactive groups was not statistically significant (Student’s t-test and Wilcoxon’s ranked sum test).

Fifty patients had bilateral synchronous SLN mapping procedures; a mean volume of 6.5 mL of blue dye (range, 1.5–10 mL) was injected into these patients. No adverse dye reaction was reported in this group.

Thirty-two patients received isosulfan blue dye a second time, during a subsequent SLN mapping procedure performed for a metachronous contralateral breast cancer or as part of prophylactic surgery. No dye reaction occurred during these metachronous SLN mapping cases.

Fifteen patients who reported a sulfa allergy were not given isosulfan blue dye during the SLN biopsy procedure because of concerns regarding cross-sensitivity. Of the 2392 individual patients in the SLN database who received isosulfan blue dye, 195 (8%) had reported a sulfa allergy. Five of the 39 patients (13%) who had a dye reaction had reported a sulfa allergy. Thus, 2.6% (5 of 195) of patients who reported a sulfa allergy had an allergic reaction to isosulfan blue dye. This incidence is not statistically significantly different from the 1.5% (34 of 2197) incidence of blue dye reactions in patients with no sulfa allergy (Fisher’s exact test).

A combination of fentanyl, propofol, midazolam, lidocaine, and/or bupivacaine was used in 33 of the 39 reactive patients (85%). These patients did not require general anesthesia for definitive surgical treatment.

Forty-one percent (16 of 39) of the reactive patients received cefazolin before surgery, compared with 42% (978 of 2353) of nonreactive patients in the SLN database. Five percent (2 of 39) of reactive patients received clindamycin, compared with 8% (197 of 2353) of nonreactive patients. No allergic reactions were noted in patients receiving any other type of antibiotic. The remaining 21 reactive patients were among the 1191 patients who received no antibiotics. The incidence of allergic reactions was not significantly different between patients who received either cefazolin or clindamycin and patients who received neither antibiotic (Fisher’s exact test).

All patients received diphenhydramine, and the more severe cases also received corticosteroids. Only the nine patients with Grade 3 reactions were administered epinephrine.

	Discussion

Top Abstract Introduction Methods Results Discussion References

 
Vital dyes, including patent blue dye and its 2,5-disulfonated isomer, isosulfan blue, have long been used for lymphangiography to identify lymphatic channel disruption. Other triphenylmethane dyes are used in industry to color textiles, cosmetics, detergents, paints, inks, antifreeze, cold remedies, laxatives, and suppositories. It has been hypothesized that prior exposure to many common products is responsible for patient sensitization to patent blue and isosulfan blue dyes (2–4).

Patent blue dye has been used in lymphangiography longer than isosulfan blue dye. Outside of the United States, it is used more frequently than isosulfan blue for SLN identification. The frequency of allergic reaction to patent blue dye has been estimated to be from 0.2% to 2.7% (4–6) (Table 1).

Case reports of allergic reactions to patent blue dye during lymphangiogram (7,13,14), and even during topical use (3,15), continue to be published. Whereas urticaria, pruritus, mucocutaneous edema, and hypotension are routinely described, bronchospasm is usually absent, but it does occasionally occur (7). Anaphylaxis to patent blue dye has also been reported (as case reports) in SLN biopsy procedures (16).

In 1982, isosulfan blue dye was approved by the Food and Drug Administration for lymphatic mapping (9). It is the only triphenylmethane dye that is approved in the United States for SLN mapping. The package insert for Lymphazurin 1% reports "a 1.5% incidence of adverse reactions. All the reactions were of an allergic type" (17).

In 1982, Hirsch et al. (9) reported a Phase III clinical trial involving isosulfan blue dye for lymphangiography. Five of 543 patients (0.9%) studied had a relatively minor allergic reaction within 15 minutes of administration of isosulfan blue dye, and all five patients recovered in one hour or less with minimal or no symptomatic therapy.

The first case of anaphylactic shock after subcutaneous injection of 0.5 mL of isosulfan blue 1% was reported by Longnecker et al. (18) in 1985. Lyew et al. (19) described an anaphylactic reaction to isosulfan blue 1% during an SLN biopsy procedure for breast cancer. The hypotension resolved after 15 minutes, and the procedure was completed. The facial swelling resolved approximately 18 hours after the event. Leong et al. (10) reported 3 cases (0.7%) of anaphylaxis after intradermal injection with isosulfan blue dye in 406 patients undergoing intraoperative lymphatic mapping for melanoma. Albo et al. (11) reported their experience of 7 cases (1.1%) of hemodynamic instability requiring epinephrine after the administration of isosulfan blue dye for SLN mapping in a series of 639 breast cancer patients.

The incidence of allergic reactions involving isosulfan blue dye in our series was 1.6%. The incidence of hypotensive reactions was 0.5%. Most reactions (69%) produced urticaria, blue hives, a generalized rash, or pruritus. Severe hypotensive reactions were rapidly responsive to antihistamines, corticosteroids, and epinephrine.

Respiratory compromise and bronchospasm were unusual manifestations of an allergic response to isosulfan blue dye in our series. Only one person (Grade 1 reaction) had wheezing, and two people (one Grade 1 reaction and one Grade 3 reaction) exhibited oxygen saturation <90%. Every patient in our series was successfully extubated at the conclusion of the case or had not required intubation at all. A number of new case reports of allergic reactions to isosulfan blue dye during SLN biopsy for melanoma (20) and breast cancer (21,22) have been recently published. In all of these reports, patients manifested urticaria with or without hypotension. None developed respiratory symptoms or required intubation.

There is inherent bias in our observation that Grade 1 reactions occur later than Grade 3 reactions (mean time, 49 and 35 minutes, respectively). Operating room staff will immediately notice the profound hypotension definitive of a Grade 3 reaction, whereas the urticaria or hives that characterize a Grade 1 reaction are often noted only on removal of the drapes at the end of the operation. As in our study, Leong et al. (10) and Albo et al. (11) noted a significant time delay (15 to 30 minutes) from dye injection to allergic reaction. It has been hypothesized that this phenomenon is due to the introduction of the antigen via an intradermal rather than an IV route (10).

It is often difficult to determine the causative agent of anaphylaxis in the absence of confirmatory testing. In many reports in the literature, the patients subsequently tested negative to the local anesthetics, which, when used at all, had been administered concomitantly (2,4–7). None of our patients underwent any of the known confirmatory tests: 1) analysis of biochemical levels of plasma histamine, plasma tryptase, or urine methyhistamine performed at the time of reaction; 2) skin-prick testing with the suspected agents; or 3) evaluation of radioimmunoassay or enzyme-linked immunoassay for drug-specific immunoglobulin E serum antibodies (10). Because of the temporal relationship between the dye injection and the reaction, we infer that isosulfan blue dye is the most probable cause of the allergic clinical response. With the exception of lidocaine, any other medication given was administered IV and earlier in the course of the operation.

Because isosulfan blue dye is the 2,5-disulfonated isomer of patent blue dye, pharmacy and operating room staff have raised concerns regarding possible cross-sensitivity in patients who report a sulfa allergy. Our data show that the sulfa allergy status of a patient has no effect on that patient’s likelihood of experiencing an allergic reaction to isosulfan blue dye. Only 2.6% of patients who reported an allergy to sulfa drugs experienced an allergic reaction, and this incidence was not statistically significantly different from the incidence of allergic reactions in patients with no reported sulfa allergy.

Isosulfan blue dye is safe for use in SLN mapping in breast cancer. It may be used in patients with a reported allergy to sulfa drugs, as well as in patients who have had previous exposure to this dye. This article highlights the need to suspect anaphylaxis when hemodynamic instability occurs after the injection of isosulfan blue dye. Discussion of the possible complication of an allergic reaction to isosulfan blue dye should be part of the preoperative consent process.

	References

Top Abstract Introduction Methods Results Discussion References

 

1. Cody HS, Fey J, Akhurst T, et al. Complementarity of blue dye and isotope in sentinel node localization for breast cancer: univariate and multivariate analysis of 966 procedures. Ann Surg Oncol 2001; 8: 13–9.[Abstract/Free Full Text]
2. Kopp WL. Anaphylaxis from alphazurine 2G during lymphography. JAMA 1966; 198: 668–9.[Abstract/Free Full Text]
3. Kalimo K, Saarni H. Immediate reactions to patent blue dye. Contact Dermatitis 1981; 7: 171–2.
4. Kalimo K, Jansen CT, Kormano M. Sensitivity to patent blue dye during skin-prick testing and lymphography. Radiology 1981; 141: 365–7.[Free Full Text]
5. Mortazavi SH, Burrows BD. Allergic reaction to patent blue violet during lymphangiography. Clin Radiol 1971; 22: 389–90.[Medline]
6. Koehler PR. Complications of lymphography. Lymphology 1968; 1: 116–20.[Medline]
7. Biran S, Hochman A. Allergic reaction to patent blue during lymphangiography. Radiol Clin Biol 1973; 42: 166–8.[Web of Science][Medline]
8. Castellino RA, Bergiron C, Markovits P. Experience with 659 consecutive lymphograms in children. Cancer 1977; 40: 1097–101.[Web of Science][Medline]
9. Hirsch JI, Tisnado J, Cho SR, Beachley MC. Use of isosulfan blue for identification of lymphatic vessels: experimental and clinical evaluation. AJR Am J Roentgenol 1982; 139: 1061–4.[Abstract/Free Full Text]
10. Leong SPL, Donegan E, Heffernon W, et al. Adverse reactions to isosulfan blue during selective sentinel lymph node dissection in melanoma. Ann Surg Oncol 2000; 7: 361–6.[Abstract/Free Full Text]
11. 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: 393–8.[Web of Science][Medline]
12. Cimmino VM, Brown AC, Szocik JF, et al. Allergic reactions to isosulfan blue during sentinel node biopsy: a common event. Surgery 2001; 130: 439–42.[Web of Science][Medline]
13. Barber CJ. Serious adverse reaction to patent blue violet at lymphography [case report]. Clin Radiol 1989; 40: 631.[Web of Science][Medline]
14. Quiliquini A, Hogendijk S, Hauser C. Anaphylaxis to patent blue. Dermatology 1998; 197: 400.[Web of Science][Medline]
15. Chadwick BL, Hunter ML, Evans MT, Hunter B. Allergic reaction to the food dye patent blue. Br Dent J 1990; 168: 386–7.
16. Vrancken Peeters MJTFD, Boutkan H, Lagaay MB, et al. Anaphylaxis to patent blue during sentinel node biopsy. Eur J Surg Oncol 2000; 26: 431–2.
17. Lymphazurin 1% [package insert]. Bedford, OH: Ben Venue Laboratories, Inc.; 1997.
18. Longnecker SM, Guzzardo MM, Van Voris LP. Life-threatening anaphylaxis following subcutaneous administration of isosulfan blue 1%. Clin Pharm 1985; 4: 219–21.[Web of Science][Medline]
19. Lyew MA, Gamblin TC, Ayoub M. Systemic anaphylaxis associated with intramammary isosulfan blue injection used for sentinel node detection under general anesthesia. Anesthesiology 2000; 93: 1145–6.[Web of Science][Medline]
20. Krouse RS, Schwarz RE. Blue dye for sentinel lymph node mapping: not too sensitive, but too hypersensitive [letter]? Ann Surg Oncol 2001; 8: 268–9.[Free Full Text]
21. Kuerer HM, Hunt KK, Singletary E, Ames FC. Blue hives during lymphatic mapping for breast cancer [letter]. J Clin Oncol 2001; 19: 2573–4.[Free Full Text]
22. Kuerer HM, Wayne JD, Ross MI. Anaphylaxis during breast cancer lymphatic mapping [letter]. Surgery 2001; 129: 119–20.[Web of Science][Medline]

This article has been cited by other articles:

				G. H. Lyman, K. J. Van Zee, and S. B. Edge Impact and Remaining Challenges in the Use of Sentinel Lymph Node Biopsy in Early-stage Breast Cancer ASCO Educational Book, January 1, 2009; 2009(1): 346 - 353. [Abstract] [Full Text] [PDF]

				Y. Liu, C. Truini, and S. Ariyan A Randomized Study Comparing the Effectiveness of Methylene Blue Dye with Lymphazurin Blue Dye in Sentinel Lymph Node Biopsy for the Treatment of Cutaneous Melanoma Ann. Surg. Oncol., September 1, 2008; 15(9): 2412 - 2417. [Abstract] [Full Text] [PDF]

				S. K. Somasundaram, D. W. Chicken, and M. R. S. Keshtgar Detection of the sentinel lymph node in breast cancer Br. Med. Bull., January 3, 2008; (2008) ldm032v1. [Abstract] [Full Text] [PDF]

				L. G. Wilke, L. M. McCall, K. E. Posther, P. W. Whitworth, D. S. Reintgen, A. M. Leitch, S. G. A. Gabram, A. Lucci, C. E. Cox, K. K. Hunt, et al. Surgical Complications Associated With Sentinel Lymph Node Biopsy: Results From a Prospective International Cooperative Group Trial Ann. Surg. Oncol., April 1, 2006; 13(4): 491 - 500. [Abstract] [Full Text] [PDF]

				G. H. Lyman, A. E. Giuliano, M. R. Somerfield, A. B. Benson III, D. C. Bodurka, H. J. Burstein, A. J. Cochran, H. S. Cody III, S. B. Edge, S. Galper, et al. American Society of Clinical Oncology Guideline Recommendations for Sentinel Lymph Node Biopsy in Early-Stage Breast Cancer J. Clin. Oncol., October 20, 2005; 23(30): 7703 - 7720. [Abstract] [Full Text] [PDF]

				A. C. Degnim, K. Oh, V. M. Cimmino, K. M. Diehl, A. E. Chang, L. A. Newman, and M. S. Sabel Is Blue Dye Indicated for Sentinel Lymph Node Biopsy in Breast Cancer Patients With a Positive Lymphoscintigram? Ann. Surg. Oncol., September 1, 2005; 12(9): 712 - 717. [Abstract] [Full Text] [PDF]

				M Currie, R K Kerridge, A K Bacon, and J A Williamson Crisis management during anaesthesia: anaphylaxis and allergy Qual. Saf. Health Care, June 1, 2005; 14(3): e19 - e19. [Abstract] [Full Text] [PDF]

				J. E. Mendez, J. V. Fey, H. Cody, P. I. Borgen, and L. M. Sclafani Can Sentinel Lymph Node Biopsy Be Omitted in Patients With Favorable Breast Cancer Histology? Ann. Surg. Oncol., January 1, 2005; 12(1): 24 - 28. [Abstract] [Full Text] [PDF]

				H. Osaka, M. Yashiro, T. Sawada, K. Katsuragi, and K. Hirakawa Is a Lymph Node Detected by the Dye-Guided Method a True Sentinel Node in Gastric Cancer? Clin. Cancer Res., October 15, 2004; 10(20): 6912 - 6918. [Abstract] [Full Text] [PDF]

				A. D. Axon and J. M. Hunter Editorial III: Anaphylaxis and anaesthesia--all clear now? Br. J. Anaesth., October 1, 2004; 93(4): 501 - 504. [Full Text] [PDF]

				T. A. King, J. V. Fey, K. J. Van Zee, A. S. Heerdt, M. L. Gemignani, E. R. Port, L. Sclafani, V. Sacchini, J. A. Petrek, H. S. Cody III, et al. A Prospective Analysis of the Effect of Blue-Dye Volume on Sentinel Lymph Node Mapping Success and Incidence of Allergic Reaction in Patients With Breast Cancer Ann. Surg. Oncol., May 1, 2004; 11(5): 535 - 541. [Abstract] [Full Text] [PDF]

				C. P. Raut, M. D. Daley, K. K. Hunt, J. Akins, M. I. Ross, S. E. Singletary, G. D. Marshall Jr, F. Meric-Bernstam, G. Babiera, B. W. Feig, et al. Anaphylactoid Reactions to Isosulfan Blue Dye During Breast Cancer Lymphatic Mapping in Patients Given Preoperative Prophylaxis J. Clin. Oncol., February 1, 2004; 22(3): 567 - 568. [Full Text] [PDF]

				H. S. Cody III Sentinel Lymph Node Biopsy for Breast Cancer: Does Anybody Not Need One? Ann. Surg. Oncol., December 1, 2003; 10(10): 1131 - 1132. [Full Text] [PDF]

				I. Bedrosian, D. Bedi, H. M. Kuerer, B. D. Fornage, L. Harker, M. I. Ross, F. C. Ames, S. Krishnamurthy, B. S. Edeiken-Monroe, F. Meric, et al. Impact of Clinicopathological Factors on Sensitivity of Axillary Ultrasonography in the Detection of Axillary Nodal Metastases in Patients With Breast Cancer Ann. Surg. Oncol., November 1, 2003; 10(9): 1025 - 1030. [Abstract] [Full Text] [PDF]

				J. Sprung, M. J. Tully, and A. Ziser Anaphylactic Reactions to Isosulfan Blue Dye During Sentinel Node Lymphadenectomy for Breast Cancer Anesth. Analg., April 1, 2003; 96(4): 1051 - 1053. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via ISI Web of Science (66) Citing Articles via Google Scholar Google Scholar Articles by Montgomery, L. L. Articles by Borgen, P. I. Search for Related Content PubMed PubMed Citation Articles by Montgomery, L. L. Articles by Borgen, P. I. Related Collections Pharmacology

Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999