We report three cases of anaphylaxis during anaesthesia confirmed on intradermal testing to be related to patent blue V dye (Guerbet – Chemical Abstract Service 3536-49-0). All three cases were associated with moderate to severe hypotension. Two cases had delayed onset, and two were associated with a rash. None of the cases were associated with bronchospasm. In all three patients the interference with pulse oximetry readings contributed to difficulties in management. We recommend the use of a test dose of blue dye prior to surgery, as suggested in the manufacturer's product information. We also recommend high vigilance for possible allergic reactions when patent blue dyes are used for sentinel lymph node mapping, because the presentations may be atypical and the reduced pulse oximetry readings may be a distraction.
HillA., TranK., AkhurstT., YeungH., YehS., RosenP.Lessons learned from 500 cases of lymphatic mapping for breast cancer.Ann Surg1999; 229: 528–535.
2.
AlbertiniJ., LymanG., CoxC., YeatmanT., BalducciL., KuN.Lymphatic mapping and sentinel node biopsy in the patient with breast cancer.JAMA1996; 276: 1818–1822.
3.
SymeD.B.Y., CollinsJ.P., MannG.B.Comparison of blue dye and isotope with blue dye alone in breast sentinel node biopsy.ANZ J Surg2005; 75: 817–821.
4.
BlessingW.D., StolierA.J., TengS.C., BoltonJ.S., FuhrmanG.M.A comparison of methylene blue and lympazurin in breast cancer sentinel node mapping.Am J Surg2002; 184: 341–345.
5.
SimmonsR.M., Rosenbaum SmithS.M., OsborneM.P.Methylene blue as an alternative to isosulfan blue for sentinel lymph node localization.The Breast Journal2001; 7: 181–183.
6.
ADRACPatent blue V and anaphylaxis.Aust Adv Drug React Bull2002; 21: 10.
7.
SprungJ., TullyM.J., ZiserA.Anaphylactic reactions to isosulfan blue dye during sentinel node lymphadenectomy for breast cancer.Anesth Analg2003; 96: 1051–1053.
8.
EfronP., KnudsenE., HirshornS., CopelandE.M.Anaphylactic reaction to isosulfan blue used for sentinel node biopsy: case report and literature review.The Breast Journal2002; 8: 396–399.
9.
MontgomeryL., ThorneA., Van ZeeK., FeyJ., HeerdtA., GemignaniM.Isosulfan blue dye reactions during sentinel lymph node mapping for breast cancer.Anesth Analg2002; 95: 385–388.
10.
AlboD., WayneJ.D., HuntK.K., RahlfsT.F., SingletaryS.E., AmesF.C.Anaphylactic reactions to isosulfan blue dye during sentinel lymph node biopsy for breast cancer.Am J Surg2001; 182: 393–398.
11.
CimminoV.M., BrownA.C., SzocikJ.F., PassH.A., MolineS., DeS.K.Allergic reactions to isosulfan blue during sentinel node biopsy – a common event.Surgery2001; 130: 439–442.
12.
LeongS.P.L., DoneganE., HefernonW., DeanS., KatzJ.A.Adverse reactions to isosulfan blue during selective sentinel lymph node dissection in melanoma.Ann Surg Oncol2000; 7: 361–366.
13.
SadiqT.S., BurnsWW3rd, TaberD.J., DamitzL., OllilaD.W.Blue urticaria: a previously unreported adverse event associated with isosulfan blue.Arch Surg2001; 136: 1433–1435.
14.
KuererH.M., HuntK.K., SingletaryS.E., AmesF.C.Unusual aspects of breast cancer: case 3 – blue hives during lymphatic mapping for breast cancer.J Clin Oncol2001; 19: 2573–2574.
15.
SchererK., BircherA., FigueiredoV.Blue dyes in medicine – a confusing terminology.Contact Dermatitis2006; 54: 231–232.
16.
SchererK., StuderW., FigueiredoV., BircherA.Anaphylaxis to isosulfan blue and cross reactivity to patent blue V: case report and review of the nomenclature of vital blue dyes.Ann Allergy Asthma Immunol2006; 96: 497–500.
17.
CurrieM., WebbR.K., WilliamsonJ.A., RussellW.J., MackayP.Australia incidence monitoring study – clinical anaphylaxis: an analysis of 2000 incident reports.Anaesth Intensive Care1993; 21: 621–625.
18.
DaleyM.D., NormanP.H., LeakJ.A., NguyenD.T., BuiT.P., KowalskiA.M.Adverse events associated with the intraoperative injection of isosulfan blue.J Clin Anesth2004; 16: 332–341.
19.
KellerB., YawalkarN., PichlerC., BraathenL.R., HungerR.E.Hypersensitivity reaction against patent blue during sentinel lymph node removal in three melanoma patients.Am J Surg2007; 193: 122–124.
20.
HuntingA.S., NoppA., JohanssonS.G.O., AndersenF., WilhelmsenV., GuttormsenA.B.Anaphylaxis to patent blue V. I. Clinical aspects.Allergy2010; 65: 117–123.
21.
MertesP.M., MalinovskyJ.M., Mouton-FaivreC., Bonnet-BoyerM.C., BenhaijoubA., LavaudF.Anaphylaxis to dyes during the perioperative period: reports of 14 clinical cases.J Allergy Clin Immunol2008; 122: 348–352.
22.
NewtonD.W., BreenP.J., BrownD.E., MackieJ.F.Jr., KluzaR.B.Physicochemical characteristics of patent blue violet dye.J Pharm Sci1981; 70: 122–127.
23.
ColemanR.L., WhittenC.W., O'BoyleJ., SidhuB.Unexplained decrease in measured oxygen saturation by pulse oximetry following injection of Lymphazurin 1% (Isosulfan Blue) during a lymphatic mapping procedure.J Surg Oncol1999; 70: 126–129.
24.
SchellerM.S., UngerR.J., KelnerM.J.Effects of intravenously administered dyes on pulse oximetry readings.Anesthesiology1986; 65: 550–552.
25.
El-TamerM., KomenakaI., CurryS., TroxelA., DitkoffB., SchnabelF.R.Pulse oximeter changes with sentinel lymph node biopsy in breast cancer.Arch Surg2003; 138: 1257–1260.
26.
KoivusaloA.M., Von SmittenK., LindgrenL.Sentinel node mapping affects intraoperative pulse oximetric recordings during breast cancer surgery.Acta Anaesthesiol Scand2002; 46: 411–414.
27.
KieckbuschH., ColdewayS., HollenhorstJ., HaeselerG., HillemannsP., HertelH.Patent blue sentinel node mapping in cervical cancer patients may lead to decreased pulse oximeter readings and positive methaemoglobin results.Eur J Anaesthesiol2008; 25: 365–368.
28.
BurgoyneL.L., JayD.W., BikhaziG.B., De ArmendiA.J.Isosulfan blue causes factitious methemoglobinaemia in an infant.Paediatr Anaesth2005; 15: 1116–1119.
29.
WöhrlS., FockeM., HinterhuberG., StinglG., BinderM.Near fatal anaphylaxis to patent blue V.Br J Dermatol2004; 150: 1037–1038.
30.
FisherM.M., BaldoB.A.Mast cell tryptase in anaesthetic anaphylactoid reactions.BJA1998; 80: 26–29.
31.
BrownS.A., BlackmanK.E., HeddleR.J.Can serum mast cell tryptase help diagnose anaphylaxis?Emergency Medicine Australasia2004; 16: 120–124.
32.
RautC.P., HuntK.K., AkinsJ.A., RossM.I., SingletaryS.E., MarshallG.D.Incidence of anaphylactoid reactions to isosulfan blue dye during breast carcinoma lymphatic mapping in patients treated with preoperative prophylaxis.Cancer2005; 104: 692–699.
33.
ThevarajahS., HustonT.L., SimmonsR.M.A comparison of the adverse reactions associated with isosulfan blue versus methylene blue dye in sentinel lymph node biopsy for breast cancer.Am J Surg2005; 189: 236–239.
34.
NourA.Efficacy of methylene blue dye in localisation of sentinel lymph node in breast cancer patients.The Breast Journal2004; 10: 388–391.
35.
GolshanM., NakhlisF.Can methylene blue only be used in sentinel lymph node biopsy for breast cancer?The Breast Journal2006; 12: 428–430.
36.
PineroA., IllanaJ., Garcia-PalencianoC., CanizaresF., CanterasM., CanadillasV.Effect on oximetry of dyes used for sentinel lymph node biopsy.Are there differences? Arch Surg2004; 139: 1204–1207.
