Cardiac Arrest after Patent Blue V Injection for Sentinel Lymph Node Biopsy in Breast Cancer

Abstract

Background: Sentinel lymph node biopsy (SLNB) is a widely accepted method to determine lymph node status in for instance breast cancer, cervical cancer, or cutaneous melanomas. Although injection of blue dyes facilitates successful detection of sentinel nodes, they have also been shown to cause adverse reactions. Case Report: A 62-year-old female patient was referred to the surgical department of the Atrium Medical Centre with a suspicious lesion located in the right breast, detected during population-based screening. Immediately after injection of patent blue V, the patient developed tachycardia on top of preexisting supraventricular tachycardia and showed an instant drop in blood pressure, after which cardiac arrest occurred. These clear symptoms of anaphylactic shock required prompt treatment, and the patient was treated accordingly. Conclusions: Anaphylactic shock after injection of patent blue V remains a serious adverse event and warrants awareness. Immediate action with ephedrine, antihistamines, and subsequently corticosteroids can stabilize the patient. Tc-99m, isosulphan blue, and methylene blue can alternatively be used for SLNB, although also not without side effects.

Case report: Atypical anaphylactic reaction to Patent Blue V dye during breast cancer surgery

“…Mechanisms underlying allergic reactions to blue dyes have not been fully elucidated. Most likely, an IgE-mediated activation of mast cell causes this allergic response (8,9). An IgE-dependent response must, of course, be preceded by exposure to blue dyes.…”

“…An IgE-dependent response must, of course, be preceded by exposure to blue dyes. PBV dye, belonging to the family of dyes from triphenylmethane, also known as E131, disulfide blue, or acid blue 3, is extensively used for commercial purposes such as in colorants in everyday objects; as a food additive; in the textile, paper, and agriculture industries; and in cosmetic and medical products; and this can explain prior sensitization (5,8,11). There is evidence that about 2,7% of the population would be allergic to blue dye (7).…”

“…PBV dye can provoke allergic reaction of varying degrees of severity (6,7). Most often these are mild reactions in the form of urticaria or erythema without hemodynamic and respiratory disorders, but sometimes can cause severe life-threating anaphylactic reaction (6,8). These reactions occur immediately or a few minutes to several hours after the injection of the dye (9).…”

“…These reactions occur immediately or a few minutes to several hours after the injection of the dye (9). The most serious allergic reaction is anaphylactic shock with circulatory failure (7,8,10,11).…”

Chromophores in operative surgery: Current practice and rationalized development

“…In particular, ICG used in this fashion is susceptible to instability in aqueous solution, concentration-dependent aggregation and rapid degradation [64]. Therefore, research has focused on increasing stability in biological fluids by altering its formulation in poly lactic glutamic acid nanoparticles and liposomes, to increase stability and prevent aggregation [65]. Unfortunately, such formulations do not alter the potential for toxicity (see Section 3.3).…”