Factitious oxygen desaturation after isosulfan blue injection

Profound pulse oximetery desaturations are observed following isosulfan blue dye injection during breast sentinel node biopsy. The objective of this study was to examine the effect isosulfan dye has on oxygenation status and the reliability of pulse oximetery in evaluating this parameter. After study design, institutional review board approval was obtained. A prospective 5-month study was performed between January and April 2002. Twenty-one women with invasive breast cancer were monitored during breast sentinel node biopsies. Twenty-two operative cases were analyzed by pulse oximetry and arterial catheterization to record oxygen saturation. Time intervals of analysis were 0, 5, 10, 20, 30, and 40 minutes following injection of isosulfan blue dye. Simultaneous pulse oximetry and arterial blood gas analysis allowed comparison of indirect oximetry oxygen saturation (SpO2) to actual arterial oxygen saturation (SaO2). SpO2 values were decreased from baseline values at 10, 20, and 30 minutes without decrease in SaO2 saturation (P < 0.001). The mean oximetry SpO2 desaturation was 5.6 per cent, with a range to 9 per cent. After injection with isosulfan blue dye, a significant SpO2 desaturation occurs. Clinicians must be aware of the factitious effect isosulfan blue dye has on SpO2 monitoring, to assess accurately the oxygenation status of the anesthetized patient.     

Adverse events associated with the intraoperative injection of isosulfan blue

STUDY OBJECTIVE: To describe the adverse events associated with the intraoperative injection of isosulfan blue in a large group of patients having a wide range of surgical procedures, and to identify risk factors for these events. DESIGN: Retrospective chart review. SETTING: University-affiliated institution specializing in malignancies PATIENTS: 1835 patients representing a total of 1852 surgical procedures. MEASUREMENTS: Incidence, type, severity, onset time, duration, management, and the presence of potential risk factors for adverse events. Events were considered "major" if potentially life-threatening hypotension occurred. MAIN RESULTS: Adverse events occurred in 28 procedures (1.5%) and 14 of these adverse events (0.75%) were classified as major. The types of events were: skin reactions in 21 patients, hypotension in 14 patients, edema in 1 patients, and unspecified in 1 patient. The time of onset for adverse events was 42.2 +/- 53.9 minutes (median, 17.5; range, 1 to 180 min) after isosulfan blue injection, and was significantly longer for minor reactions compared with major events (p = 0.015). The longest adverse event lasted at least 21 hours. Treatment was successful with usual antiallergy/antianaphylaxis medications. Ten patients received diphenhydramine alone, and four patients received intravenous epinephrine infusions. Factors associated with a significantly increased incidence of adverse events were isosulfan blue injection in the vulvar area (p = 0.000038), and the chronic preoperative use of angiotensin-converting enzyme inhibitors or angiotensin receptor-blocking agents (p = 0.043). Trends toward an increased risk of an adverse event were noted with isosulfan blue injection in the breast area (p = 0.19), and having more than one surgical procedure with isosulfan blue (p = 0.14). CONCLUSIONS: Although the most frequent adverse event associated with injection of isosulfan blue was a skin reaction, potentially life-threatening hypotension occurred in 0.75% of all procedures. Anesthesiologists must be aware of the variable onset time and potentially prolonged duration of the adverse events. They should recognize the need for extra vigilance in patients with potential risk factors, and have the usual antiallergy/antianaphylaxis medications available for administration if necessary.     

Intraoperative decrease in pulse oximeter readings following injection of isosulfan blue

PURPOSE: Sentinel lymph node mapping, involving injection of isosulfan blue dye around a tumour, is beginning to be used in patients with carcinoma of the breast. Absorption of the dye into the circulation may interfere with pulse oximetry, causing falsely low readings. This report describes changes in pulse oximeter readings following injection of isosulfan blue for sentinel lymph node mapping in a patient with carcinoma of the breast. CLINICAL FEATURES: An 83-yr-old female patient underwent sentinel node biopsy of the axilla followed by partial mastectomy for carcinoma of the left breast. Isosulfan blue was injected in the area of the tumour in the left breast. The SpO2 began to decrease 15 min after dye injection, reaching a nadir of 89-90% 30 min after injection. Arterial blood gas analysis showed normal arterial partial pressure of oxygen. Pulse oximeter readings did not return to normal until more than six hours after dye injection. CONCLUSION: Review of the literature reveals a small number of case reports of similar occurrences of low pulse oximeter readings following injection of isosulfan blue or patent blue dye for lymphatic mapping. Data from these reports and the case described here suggest that the latency, magnitude and duration of effect on pulse oximeter readings following injection of these dyes is highly variable. It is important to rule out other causes of low pulse oximeter readings when this effect occurs; normal oxygenation can be verified with arterial blood gas analysis. Co-oximetry can be done to rule out methemoglobinemia as a cause of decreased SpO2.     

Thigh isosulfan blue injection in the treatment of postoperative lymphatic complications.

Postoperative lymphatic complications after infrainguinal revascularization are troublesome and potentially serious complications. Vital dye injection into the web spaces of the foot has been recommended as a simple and reliable method to identify lymphatic channel disruption before groin exploration. Such distal injections, however, are not always successful. We describe a modified technique using a proximal thigh injection with isosulfan blue, which is faster and more useful than the distal web space method.     

Low-flow transtracheal rescue insufflation of oxygen after profound desaturation

BACKGROUND: The objective of this study was to determine whether low-flow transtracheal insufflation of oxygen (TRIO) could rescue an animal from profound desaturation. This temporizing maneuver could be useful during cannot-intubate or -ventilate scenarios by resolving hypoxia without the morbidity associated with more invasive procedures. METHODS: Seven swine for a total of 12 runs were studied. Animals were pharmacologically anesthetized, paralyzed, and mechanically ventilated with room air. After disconnection from the ventilator and desaturation to an Spo2 < 50%, low-flow TRIO (2 L/min) was administered for 1 hour. RESULTS: All animals survived and Spo2 increased to greater than 90% in 23 seconds on average. Pao2 (mean, 183 mm Hg) remained elevated throughout the study. Hemodynamic stability was maintained for at least 15 minutes. CONCLUSION: Low-flow TRIO rescued animals from profound hypoxia and maintained oxygenation for at least 1 hour. Low-flow TRIO did not prevent hypercarbia with its subsequent sympathetic activation.     

A comparison of methylene blue and lymphazurin in breast cancer sentinel node mapping

BACKGROUND: When lymphazurin became unavailable to our institution, we elected to employ methylene blue to perform sentinel node mapping for patients with breast cancer. The purpose of this study was to compare methylene blue and lymphazurin for performing sentinel node mapping for breast cancer. METHODS: We evaluated our sentinel node mapping experience from April 1, 2001 to March 31, 2002. Patients were divided into two groups based on the dye used for lymphatic mapping. The two groups were compared to evaluate the results of the sentinel node mapping procedure. RESULTS: During the study period a total of 199 patients were evaluated with sentinel node mapping, 87 with lymphazurin and 112 with methylene blue. The two groups were similar in demonstrating the success of the sentinel node procedure, nodes identified per case, and technique used for node identification (colloid or dye, or both). CONCLUSIONS: In our initial experience, methylene blue appears to be equivalent to lymphazurin for sentinel node mapping in breast cancer.     

Nocturnal arterial oxygen desaturation and episodic airway obstruction after ambulatory surgery

Some patients experience disordered breathing during sleep and arterial oxygen desaturation after major inpatient surgery. We performed this study to determine whether similar events occur after ambulatory surgery. Forty-five ambulatory surgery patients received an unrestricted anesthetic. Continuous unattended nocturnal recordings of breathing pattern and oxygen saturation were made in the patients' homes before surgery and during the first and second postoperative nights. Nine patients had a respiratory disturbance index >10 and/or >1% of recording time with oxygen saturation <90% on at least one study night. These nine patients had a significantly older median age and a significantly larger median body mass index. Their median respiratory disturbance index and median percentage of time with oxygen saturation <90% were significantly higher on the first postoperative night than on the preoperative night.     

Staining of endotracheal tube with isosulfan blue dye after sentinel node mapping: a case report

Sentinel node mapping is successfully performed for the detection of cancer and nodal metastasis. There is a reported complication rate of 1.5%, most being mild allergic reactions, with a few rare reported cases of anaphylaxis. Isosulfan blue has been found to routinely create a modest artifactual desaturation via pulse oximetry, as well as a transient skin discoloration that may last for several hours to weeks. It causes discoloration of urine and has been detected in other body secretions, none of which have been found to be of clinical significance. This is a case report involving a 61-year-old woman who underwent sentinel node mapping and axillary dissection for breast adenocarcinoma. On postoperative extubation, the endotracheal tube was noted to be stained dark blue with isosulfan dye. This unusual complication is unreported to date and is likely the result of systemic absorption of the dye.     

The absence of arterial oxygen desaturation during massive oxygen embolism after hydrogen peroxide irrigation

For decades, water-mill murmur, decrease in end-tidal CO(2) (Petco(2)), hypotension, and hypoxemia have been accepted as diagnostic criteria for gas embolism. In this case report, a 19-yr-old male patient developed a sudden reduction in Petco(2) and profound circulatory collapse 15 min after intramedullary irrigation with H(2)O(2). However, arterial oxygen desaturation never developed throughout the entire course of resuscitation from presumed massive oxygen embolism.     

Continuous assessment of oxygen saturation and subcutaneous oxygen tension after abdominal operations

Ten patients undergoing abdominal operations had oxygen saturation (SpO2) and transcutaneous (PtcO2) and subcutaneous (PscO2) oxygen tensions monitored continuously during the second and third postoperative nights from 11 pm to 7 am. At the end of the second postoperative night an oxygen stimulation test (10 l/min by face mask) was carried out in eight of the 10. Median SpO2 was 91% (range 82-95) on the second, and 91% (86-95) on the third, postoperative nights, respectively. Six patients had intermittent episodes of desaturation to less than 80%, each of less than one minute's duration. PtcO2, but not PscO2, followed the episodic variations in SpO2. PscO2 was 58 mmHg (46-69) on the second postoperative night and 61 mmHg (48-71) on the third postoperative night. PscO2 correlated with SpO2 in all but one patient who had lower PscO2 than expected from the measured SpO2 and estimated PaO2. Oxygen treatment increased individual PscO2 by 14 mmHg (9-49), PtcO2 by 38 mmHg (10-104), and SpO2 to 99% (95-100), but stable PscO2 was not achieved within the 20 minute period of treatment. These results obtained during continuous measurements show pronounced intersubject differences in oxygen tensions near the surgical wound in the late postoperative period. The results suggest that pulmonary oxygenation is the most important determinant of mean subcutaneous oxygen tension after uncomplicated elective abdominal operations.     

A cautionary tale: anaphylaxis to isosulfan blue dye after 12 years and 3339 cases of lymphatic mapping

Sentinel node biopsy has become the standard method for lymphatic staging in early-stage breast cancer and melanomas. The most commonly used technique uses both a radioactive tracer as well as blue dye, usually isosulfan blue. In this report, we discuss two episodes of anaphylaxis to isosulfan blue during lymphatic mapping, occurring 12 years and 3339 lymphatic mapping cases after adoption of the technique, and discuss management issues raised by these events.     

小儿气道异物取出术中及术后发生去氧饱和的危险因素

目的 筛选小儿气道异物取出术中及术后发生去氧饱和的危险因素.方法 选择2007年2月至2008年10月就诊于本院的气道异物患儿301例,年龄5月～12岁,ASA Ⅰ或Ⅱ级,记录患儿术前合并症情况、异物留存时间、异物种类、异物位置、通气方式、置入硬支气管镜时体动反应的发生情况、术后喉痉挛的发生情况、手术时间、拔管时麻醉深度、苏醒时间及术中、术后去氧饱和的发生情况.脉搏血氧饱和度<90%并超过5 S定义为发生去氧饱和.采用logistic回归分析筛选术中及术后发生去氧饱和的危险因素.结果 术中去氧饱和的发生率为20.4%,术后去氧饱和的发生率为12.2%.logistic回归分析结果显示术前合并肺炎、异物种类为植物种子类、手术时间>20 min、保留自主呼吸的通气方式是患儿术中发生去氧饱和的危险因素;异物种类为植物种子类及苏醒时间延长是患儿术后发生去氧饱和的危险因素.结论 术前合并肺炎、异物种类为植物种子类、手术时间>20 min、保留自主呼吸的通气方式是患儿术中发生去氧饱和的危险因素;异物种类为植物种子类及苏醒时间延长是患儿术后发生去氧饱和的危险因素.     

Investigation of anaphylactic reaction after patent blue V dye injection

Most patients experiencing a severe allergic reaction to PBV have no past medical history of allergy. The exact mechanism of PBV-related anaphylaxis remains unknown. The value of formal allergy skin testing for PBV-related allergy lies in excluding other agents as the causative factor to avoid their exposure in the future.

Conflict of Interest Statement

None declared.     

Optimal number of sentinel nodes after intradermal injection isotope and blue dye

BACKGROUND: Sentinel node (SN) biopsy for breast cancer is becoming more common owing to its lower morbidity when compared with full axillary dissection. However, the optimal method of finding and the number of SN to be dissected are still subject to conjecture. The aim of this study was to determine the optimal number of SN required to accurately stage an axilla after the i.d. injection of isotope and blue dye. METHOD: Prospective data from all patients undergoing SN biopsy from April 2000 to September 2004 were analysed. For positive SN, the order in which they became positive was then tabulated. RESULTS: During the 4 years, 113 patients who fulfilled the selection criteria had undergone SN biopsy with 216 SN harvested. Of these, 33 patients had positive SN results. If only the first SN was analysed, 87.9% of those positive biopsies would have been discovered. Two SN raised the predictive value to 97.0%. CONCLUSION: Two SN would seem to be the optimal number to harvest after i.d. injection of both isotope and blue dye.     

Effect of pH modification by bicarbonate on pain after subcutaneous lidocaine injection

Objective

To quantify the pain experienced on subcutaneous injection of lidocaine, lidocaine with sodium bicarbonate (NaHCO₃) and saline.

Design

A double-blind randomized prospective study.

Setting

A clinical research unit in a university-affiliated hospital.

Participants

Forty-two healthy adult volunteers who did not have a history of adverse reaction to lidocaine or peripheral neuropathy and were not pregnant. The study was performed in two phases. In Phase 1, 1 mL each of thee solutions (2 mL of 8.4% NaHCO₃ in 20 mL 1% lidocaine, 2 mL saline in 20 mL lidocaine and saline alone) were injected by an investigator, blinded as to the identity of the solutions, in random order to five volunteers to measure onset and duration of anesthesia and the perceived pain on injection. In Phase 2, 37 volunteers were injected with the three solutions in random order, by an investigator blinded as to the identity of the solutions.

Main Outcome Measure

Pain on injection measured with the visual analogue scale.

Results

There were no clinically significant differences between onset and duration of action of lidocaine with and without NaHCO₃, as determined by Kruskal–Wallis one-way analysis of variance and the Wilcoxon signed-ranks test. Injection of lidocaine with NaHCO₃ was significantly less painful than injection of plain lidocaine (p = 0.041). Injection of saline was the most painful.

Conclusion

The addition of NaHCO₃ to lidocaine produces significant reduction in pain experienced on injection without significantly affecting the onset or duration of action.     

Muscle and subcutaneous oxygen tension. Measurements by mass spectrometry after sympathectomy.

Utilizing the mass spectrometer, tissue oxygen tension (TPO2) in the resting state was measured in the extremities of ten dogs before and after lumbar sympathectomy. Although there was considerable variation between individual dogs, significant changes in tissue oxygenation were not consistently obtained in the group as a whole, althouth femoral arterial blood flow increased in all animals. Using TPO2 changes to estimate perfusion, no significant increase in nutritive flow could be demonstrated.     

Multicenter trial of sentinel node biopsy for breast cancer using both technetium sulfur colloid and isosulfan blue dye

OBJECTIVE: To determine the factors associated with false-negative results on sentinel node biopsy and sentinel node localization (identification rate) in patients with breast cancer enrolled in a multicenter trial using a combination technique of isosulfan blue with technetium sulfur colloid (Tc99). SUMMARY BACKGROUND DATA: Sentinel node biopsy is a diagnostic test used to detect breast cancer metastases. To test the reliability of this method, a complete lymph node dissection must be performed to determine the false-negative rate. Single-institution series have reported excellent results, although one multicenter trial reported a false-negative rate as high as 29% using radioisotope alone. A multicenter trial was initiated to test combined use of Tc99 and isosulfan blue. METHODS: Investigators (both private-practice and academic surgeons) were recruited after attending a course on the technique of sentinel node biopsy. No investigator participated in a learning trial before entering patients. Tc99 and isosulfan blue were injected into the peritumoral region. RESULTS: Five hundred twenty-nine patients underwent 535 sentinel node biopsy procedures for an overall identification rate in finding a sentinel node of 87% and a false-negative rate of 13%. The identification rate increased and the false-negative rate decreased to 90% and 4.3%, respectively, after investigators had performed more than 30 cases. Univariate analysis of tumor showed the poorest success rate with older patients and inexperienced surgeons. Multivariate analysis identified both age and experience as independent predictors of failure. However, with older patients, inexperienced surgeons, and patients with five or more metastatic axillary nodes, the false-negative rate was consistently greater. CONCLUSIONS: This multicenter trial, from both private practice and academic institutions, is an excellent indicator of the general utility of sentinel node biopsy. It establishes the factors that play an important role (patient age, surgical experience, tumor location) and those that are irrelevant (prior surgery, tumor size, Tc99 timing). This widens the applicability of the technique and identifies factors that require further investigation.