D1.75 - Anaphylaxis during Picc Line replacement

We report the clinical case of a 45-year-old patient undergoing chemotherapy with Navelbine for metastatic pleomorphic lung carcinoma, who experienced an anaphylactic shock with respiratory arrest following the replacement of a BD (Power PICC Solo) peripherally inserted central catheter (PICC Line).

The anesthesiologist described the following sequence: local anesthesia with lidocaine after disinfection with alcoholic Betadine (no chlorhexidine), followed by PICC Line replacement (10 minutes) and then flushing of the PICC Line.

Less than one minute after the flushing, while the dressing was being applied, the patient exhibited agitation, chest tightness, pharyngeal pruritus, followed by respiratory arrest and vasoplegic shock requiring intubation, administration of epinephrine, and admission to the intensive care unit. Subsequently, the patient developed eyelid and ear edema, along with profuse diarrhea.

The anesthesiologist confirmed that nothing other than normal saline had been injected. The PICC Line was kept in place as it was not considered a suspect during the acute phase of anaphylaxis.

Tryptase levels measured at 1 hour were 197 µg/L, and histamine levels were >100 nmol/L, indicating mast cell degranulation. Baseline tryptase levels were normal at 6.4 µg/L.

Specific IgE tests for lidocaine, chlorhexidine, and latex were negative.Skin tests for latex, alcoholic and aqueous Betadine, and both aqueous and alcoholic chlorhexidine were also negative. Additionally, skin tests for lidocaine were negative, and lidocaine was reintroduced subcutaneously at a dose of 1.2 mL with good tolerance.

However, intradermal tests (IDT) at 1/10 dilution and undiluted IDT (confirmed twice) were positive for the flushing solution used in the PICC Line (1 mL of normal saline used to flush a new PICC Line of the same brand as the one inserted).

These findings indicate an IgE-mediated allergy to a substance present in the brand-new PICC Line.

The patient’s PICC Line was subsequently reused for chemotherapy with good tolerance. A conventional peripheral venous catheter (PVC) was also used again without adverse reactions.

A literature review revealed that cases of anaphylaxis have previously been reported with PICC Lines of the same brand (1). A spectrophotometric analysis of the flushing solution was performed with a band-new PICC Line, but it did not identify any specific allergen.To date, the exact nature of the allergen remains unknown.

(1) Anaphylaxis and anaphylactoid reactions associated with the insertion of peripherally inserted central catheters: A multiyear comparative retrospective cohort study Christina S. Thornton PhD, MD1 , Jody Dumanski RN2 , Cherylanne Margherit RN2 , Sandra Vaz-Gonsalves