International Journal of Critical Illness and Injury Science

CASE REPORT
Year
: 2019  |  Volume : 9  |  Issue : 4  |  Page : 203--205

Swan-Ganz catheter causing anaphylactic shock: A rare case report


Muhammad Usman Asghar1, Sanwal Singh Mehta2, Hira Asif Cheema3, Krishna Kommineni2,  
1 Department of Surgery, New York University School of Medicine, New York, NY, USA
2 Department of Internal Medicine, Maimonides Medical Center, New York, NY, USA
3 Department of Internal Medicine, Shifa College of Medicine, Islamabad, Pakistan

Correspondence Address:
Dr. Muhammad Usman Asghar
Department of Surgery, New York University School of Medicine, Science Building, 435 E. 30th Street, 4th Floor, New York, NY 10016
USA

Abstract

Latex-induced anaphylactic reactions are often underestimated in patients having procedures in a catheterization lab, intensive care units, or in operating rooms. Most physicians are not aware that almost all balloons in the Swan-Ganz catheter (SGC) are made up of latex. Direct exposure of these latex balloons in the blood can cause severe anaphylactic reactions, even in patients with no previous history of allergies. We present a case of a 53-year-old male, who underwent a SGC placement for cardiovascular evaluation. Immediately after the SGC insertion, he developed circulatory shock. On further investigation, we discovered that SGC balloon contained latex as one of the components. Physicians should be aware of latex-based products such as SGC balloon, which can cause anaphylactic shock even in case of no prior allergies to latex.



How to cite this article:
Asghar MU, Mehta SS, Cheema HA, Kommineni K. Swan-Ganz catheter causing anaphylactic shock: A rare case report.Int J Crit Illn Inj Sci 2019;9:203-205


How to cite this URL:
Asghar MU, Mehta SS, Cheema HA, Kommineni K. Swan-Ganz catheter causing anaphylactic shock: A rare case report. Int J Crit Illn Inj Sci [serial online] 2019 [cited 2020 Mar 31 ];9:203-205
Available from: http://www.ijciis.org/text.asp?2019/9/4/203/272768


Full Text



 Introduction



Latex allergy is a Type I IgE-dependent hypersensitivity reaction. Latex-related allergies are becoming an increasing concern in operating rooms and outpatient surgical procedures. These reactions can range from mild dermatitis to severe life-threatening anaphylactic shock. The severity of the reaction depends on the previous history and level of exposure to patients. In many circumstances, patients do not have any previous exposure or do not recall the first exposure. Upon the use of latex-based products in the procedure rooms, patients can experience severe anaphylactic shock. Previously documented allergies, particularly to latex, can prevent these reactions, but in some patients, there is no prior history of latex allergy, and they develop severe anaphylactic reaction on direct exposure to latex in the blood. We present such a case of a 53-year-old male, who underwent a Swan-Ganz catheter (SGC) placement for cardiovascular evaluation and developed circulatory arrest. In such conditions, physicians should be ready to prevent any worse outcome and use the latex-free catheters to have a favorable prognosis.

 Case Report



A 53-year-old male with a past medical history of hypertension, diabetes mellitus, obstructive sleep apnea, and congestive heart failure presented to the emergency department for increasing shortness of breath (SOB) over the past 2 weeks. He complained of SOB when lying down and when walking more than one block. He had no prior history of coronary artery disease, but previously an automated cardiovascular defibrillator was placed for nonischemic cardiomyopathy. In the emergency room, his vitals were temperature: 98.1°F, pulse rate: 108/min, respiratory rate: 20/min, blood pressure: 120/87 mmHg, and SpO2: 97%. His serum electrolytes were within normal limits, serum brain natriuretic peptide level was 776 pg/mL, and serum troponin was 0.15 ng/mL. His echocardiography showed severely decreased left ventricular ejection fraction (6%–10%), cardiomyopathy, moderately dilated left ventricular cavity, moderately reduced right ventricular function, and dilated left atrium. He was admitted to the hospital for acute on chronic systolic heart failure. He was initially started on Lasix drip, metolazone, and spironolactone for medical management. He improved on medication and was planned for right-heart catheterization (RHC) after medical stabilization. During the first RHC, he became hypoxemic and hypotensive. He was immediately transferred to the coronary intensive care unit on milrinone and vasopressin. He was stabilized and planned for bedside SGC. At the end of the procedure, he started to complain of itching all over his body. Then within seconds, he went into respiratory failure and cardiac arrest (pulseless electrical activity). The patient was managed according to the advanced cardiac life support protocols. He was intubated after developing anaphylaxis and was treated with epinephrine, intravenous steroids, and antihistamines. Due to the concern of cardiac tamponade and pericardial effusion, bedside ultrasonography (USG) was performed. There was no evidence of pericardial tamponade on USG. The patient had hives and rash all over his body postcardiopulmonary resuscitation. It was determined that the patient likely developed anaphylaxis during SGC placement. On investigation, it was discovered that the SGC contained latex as one of the components. The patient had no prior history of allergy to latex products. He was monitored in the cardiac care unit. He was subsequently extubated after improvement and planned to be discharged. He was recommended to follow-up with the heart failure team and an allergy specialist.

 Discussion



Allergic reactions can present as urticarial rash, erythema, bronchospasm, and anaphylactic shock. Allergies in the operating room or during minor procedures are usually from anesthesia or latex-based products. The incidence of latex allergy in the general population is expected to be 1–2%.[1] Latex allergy occurs due to certain proteins found in the products made from natural rubber latex. Two types of allergic reactions are documented on latex exposure; local reactions involving the skin and severe life-threatening anaphylactic reactions in case of mucosal or parenteral exposure.[2] Skin reactions are more frequent in health-care workers due to exposure to latex gloves,[3] while anaphylactic reactions are more common in patients with spina bifida due to continuous exposure of latex through intermittent urinary catheterization.[4] Other patients susceptible to anaphylactic reaction are those undergoing procedures such as pulmonary catheterization where there is direct exposure to latex balloon in the blood.

Latex allergy is caused by Type I and Type II hypersensitivity reactions.[5] The pathophysiology of Type I hypersensitivity reaction involves the stimulation of B-cells on exposure of antigen. This leads to the production of IgE antibody specific to the antigen. During the sensitization phase, IgE antibodies bind to mast cells and basophil cells. Re-exposure to the same antigen directly binds to previously made IgE-coated mast cells. This results in massive degranulation of histamine, leukotrienes, and prostaglandins. These substances cause pruritus, erythema, vasodilation, and in severe cases, anaphylactic shock. Severe Type I hypersensitivity reactions to latex exposure can manifest as cardiovascular collapses such as hypotension, tachycardia, and hypoxemia.[6]

Latex can also cause a Type IV hypersensitivity reaction similar to contact dermatitis.[7] In a study, the latex was shown to have cross-reactivity against certain fruits such as banana, avocado, and kiwi.[8] If a patient is allergic to latex, the likelihood of having kiwi, banana, or avocado allergy is reported to be 35%. Alternatively, if the patient has fruit allergies, the probability of having latex allergy is 11%.[9] Atopy is another contributing risk factor for developing latex allergy.[10]

Most health-care providers are not fully aware that most of the SGC contains a balloon made of latex. The use of SGC can jeopardize patients, particularly those who have been previously exposed to latex. Patients with cross-reactivity to fruits or with no previous allergies are prone to develop latex allergy. This allergy can be diagnosed by medical history, skin prick testing, or detection of specific IgE antibody against latex. Allergy to SGC can be confirmed by skin prick testing using the balloon extract. Allergic reaction secondary to SGC procedure is more severe due to the latex balloon being directly exposed to the blood. This direct exposure can result in severe anaphylactic shock and death. Latex-free products such as silicon, plastic, and polyvinyl chloride should be considered in high-risk patients to prevent any devastating consequences.[6] The increased use of latex-based products is becoming a major concern. Physicians should take a detailed medical history and perform preprocedural skin testing or IgE radioallergosorbent test in high-risk patients. Physicians should be aware of latex-based products such as SGC balloon which is made up of latex and can cause shock and death even in patients with no prior history of allergies.

 Conclusion



Latex allergy should be considered in patients having anaphylaxis reactions of unknown origin during surgical procedures.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patient understands that his/her name and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. The authors followed applicable EQUATOR Network (http://www.equator-network.org/) guidelines during the preparation of this report.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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