Profound hypotension after an intradermal injection of indigo carmine for sentinel node mapping.

© 2013 Korean Breast Cancer Society. All rights reserved. http://ejbc.kr | pISSN 1738-6756 eISSN 2092-9900This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Indigo carmine (sodium indigotindisulfonate) was intro - duced in 1904 and is commonly used for locating the ureteral orifice, a severed ureter, or a fistula [1]. In Japan, sentinel node biopsy using indigo carmine has been performed since 1998 for breast surgery . Despite its long-term use, no adverse reac - tion has been reported after the intradermal injection of indigo carmine during breast surgery . However, rarely adverse reac - tions, such as, hypotension, bradycardia, and cardiac arrest, have been reported after an administration of indigo carmine, intravenously, during urologic or gynecologic surgery [2-4], and one report has described severe hypotension in a patient administered indigo carmine, intravaginally [5]. W e experienced two cases of profound hypotension after an intradermal injection of indigo carmine into the periareo - lar area during breast surgery . The patients were 57-year-old (154 cm/64 kg) and 46-year-old (166 cm/66 kg) women with invasive ductal carcinoma in the left breast scheduled for breast-conserving surgery. Both had no history of allergy or previous exposure to indigo carmine. One of them had a his - tory of diabetes mellitus and had undergone total abdominal hysterectomy (T AH) due to uterine myoma and endometrio - sis 2 years previously . She had not been administered indigo carmine during TAH. Under general anesthesia, the usual preparations for breast cancer surgery were performed. The patients’ vital signs were stable without the signs of massive bleeding or volume depletion. Before the main surgical proce - dure, after confirming of no blood aspiration, 5 mL of indigo carmine (0.8% sodium indigotindisufonate; Korea United Pharm., Seoul, Korea) was injected intradermally around the subareolar area at the 3, 6, 9, and 12 o ’ clock positions. In the first patient, blood pressure was not measurable by noninva - sive blood pressure monitoring and no carotid or femoral pulse was detected 1 minute after indigo carmine administra - tion. After the administration of phenylephrine (100 μg), a right radial arterial line was blindly inserted. Two minutes after the readministration of phenylephrine (100 μg), carotid pulsation was detected and gradually strengthened; blood pressure was restored from 30/10 to 150/94 mm Hg. In the second case, immediately after the indigo carmine injection, blood pressure suddenly dropped to 50/30 mm Hg. Intrave - nous ephedrine (10 mg) was administered twice and blood pressure was restored to 144/89 mm Hg within 5 minutes. Before the hemodynamic event, no other components, such as muscle relaxant, and blood components were administered to the patients, and both had no evidence of skin rash or sign of bronchospasm, and heart rate were maintained at 60 to 70 beats per minute without electrocardiogram change during the events. No other adverse events occurred during the last - ing operation and the postoperative period. Sentinel lymph node biopsy in breast cancer provides a means of reducing postoperative morbidity and improving Profound Hypotension after an Intradermal Injection of Indigo Carmine for Sentinel Node Mapping Y oun Yi Jo, Mi Geum Lee, Soon Y oung Y un, Kyung Cheon Lee Department of Anesthesiology and Pain Medicine, Gachon University Gil Medical Center, Incheon, Korea B R I E F C O M M U N I C AT I O N J Breast Cancer 2013 March; 16(1): 127-128 http://dx.doi.org/10.4048/jbc.2013.16.1.127 Intradermal injections of indigo carmine for sentinel node map- ping are considered safe and no report of an adverse reaction has been published. The authors described two cases of pro - found hypotension in women that underwent breast-conserving surgery after an intradermal injection of indigo carmine into the periareolar area for sentinel node mapping. Key Words: Breast neoplasms, Hypotension, Indigo carmine, Intradermal injections, Sentinel lymph node biopsy Correspondence to: Kyung Cheon Lee Department of Anesthesiology and Pain Medicine, Gachon University Gil Medical Center, 21 Namdong-daero 774beon-gil, Namdong-gu, Incheon 405-760, Korea T el: +82-32-460-3636, Fax: +82-32-469-6319 E-mail: [email protected] Received: November 28, 2012 Accepted: January 20, 2013 Journal of BreastCancer 128  Y oun YiJo,etal. http://ejbc.kr http://dx.doi.org/10.4048/jbc.2013.16.1.127 quality of life by preventing excessive axillary dissection. The selection of blue dye or technetium radioisotope for lymphatic mapping depends on the surgeon’s preference. Although several reports [6,7] of an anaphylactoid reaction after the administration of isosulfan blue dye have been issued, no such report has been previously issued of such a reaction following the intradermal injection of indigo carmine. Indigo carmine has stimulant and depressant effects. Although side effects are rare, the similar molecular structures of indigo carmine and serotonin suggest a common molecular basis for hemo - dynamic events [2-4,8]. Hypertension associated with indigo carmine has been attributed to vasoconstriction caused by a direct α-adrenergic activation or by the release of catechol - amines leading to an increase in the total peripheral resistance, and diastolic and systolic blood pressures [8]; that is, in the same manner as serotonin. On the other hand, suppressive events have been presumed to be caused by an anaphylactoid or idiosyncratic reaction to dye [2,3]. Anaphylactoid reactions may occur after initial exposure to a substance and are not immunologically mediated reactions [9]. In some case reports, idiosyncratic anaphylactoid reaction was considered as the cause of abrupt severe hypotension without concurrent ana - phylactic signs, such as, skin erythema or rash or a reactive airway reflex [2,3,9]. In this described cases, we only experi - enced severe hypotension without an anaphylactic reaction. It is notable that the majority of cases occur after an intravenous injection [2-4], whereas in our cases, incidents occurred after an intradermal injection, which is clinically considered safe. Although hypotensive events usually subside rapidly after the injection of ephedrine or phenylephrine, sometimes they can lead to catastrophic complications like cerebral ischemia [2]. Another possible explanation is the presence of impurities in the law materials, reagents, and degradation during manufac - ture and storage in this drug [10]. There were five hypotensive events after intravenous injection of indigo carmine with the same lot number during a short period and determined the presence of impurities in the raw material. Important point is that they did not prevent a hypotensive event, even in the diluting indigo carmine in normal saline and to administer it slowly over 5 minutes. Therefore, careful monitoring and vasopressor preparation is important before using indigo carmine. CONFLICT OF INTEREST The authors declare that they have no competing interests. REFERENCES 1. Deture F A, Drylie DM. Evaluation of indigo carmine as an indicator of renal function. J Urol 1974;112:693-6. 2. Lee WJ, Jang HS. Cardiac arrest from intravenous indigo carmine dur - ing laparoscopic surgery: a case report. Korean J Anesthesiol 2012;62: 87-90. 3. Nguyen AC, Kost E, Framstad M. Indigo carmine-induced severe hy - potension. Anesth Analg 1998;87:1194-5. 4. Satoh K, Sakamoto N, Shinohe Y , Satoh M, Joh S. Indigo carmine-in - duced bradycardia in a patient during general anesthesia. Anesth Analg 2001;92:276-7. 5. Y anagidate F , Hamaya Y , Dohi S. V aginal indigo carmine-induced se - vere hypotension. Anesth Analg 2001;92:556-7. 6. Raut CP , Daley MD, Hunt KK, Akins J, Ross MI, Singletary SE, et al. 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