Alisa C. Thorne

UNLABELLED: In the United States, identification of the sentinel lymph node (SLN) requires the use of (99m)Tc-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.

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.

Esmolol infusion at rates of 200, 300, and 400 μg·kg−1·mm−1 was used to potentiate hypotension (mean arterial pressure = 60 mm Hg) induced with sodium nitroprusside (SNP) in 10 male patients undergoing radical cancer surgery during nitrous oxide-oxygen and fentanyl anesthesia. Heart rate (HR), blood pressure (radial arterial catheter), and plasma levels of renin activity (PRA), norepmephrine (N), epinephrine (E), and dopamine (D) were measured: 1) while patients were awake; 2) after induction of anesthesia (nitrous oxide, 60% in oxygen, fentanyl = 5 μg/kg followed by an infusion at 10 μg·kg−1 ·hr−1); 3) after surgery had begun: 4) after 20 minutes of SNP-induced hypotension; 5) after 20 minutes of esmolol at each of the above infusion rates; and 6) after the completion of surgery. Compared to awake values, SNP-induced hypotension (mean infusion rate = 3.1 μg·kg−1·min−1 ± 0.6 SE] during surgery resulted in significant (P < 0.05) increases in heart rate, PRA, N, and D. Infusion of esmolol resulted in significant (P < 0.05) dose-dependent reductions in SNP requirement to maintain MAP = 60 mm Hg. At 200 μg·kg−1·min−1, SNP requirement was 2.1 μg·kg−1·min−1 ±0.4, at 300 μg·kg−1·min−2, it was 1.0 μg·kg−1·min−1 ±0.2, and at 400 μg·kg−1·min−1, was 0.5 μg·kg−1·min−1 ±0.3. Concomitant with the decrease in SNP requirement, there were significant reductions in HR and PRA at all infusion rates of esmolol. At 300 μg·kg−1·min−1, there was a significant (P < 0.05) increase in PaO2 (141 mm Hg ± 18 to 162 mm Hg ± 16, and decrease in N (615 pg/ml ± 105 to 356 pg/ml ± 56) and E (74 pg/ml ± 20 to 57 ± 10). No rebound hypertension was observed at the end of SNP-esmolol infusion, and HR, BP, PaO2, PRA, N, and D levels were not different from awake values. Only E levels were elevated postoperatively (460 pg/ ml ± 98 vs 63 pg/ml ± 8 preoperatively, P < 0.05). The authors conclude that esmolol infusion is a safe and effective pharmacologic means of potentiating SNP-induced hypotension during fentanyl-N2O-O2 anesthesia. Esmolol acts by counteracting many of the adverse endocrine and baroreceptor-mediated effects of SNP, and the short half-lives of esmolol and SNP permit contemporaneous termination of action when they are simultaneously discontinued.