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Table of Contents
CASE REPORT  
Year : 2016  |  Volume : 19  |  Issue : 3  |  Page : 557-560
Cetrimide-chlorhexidine-induced multiorgan failure in surgery of pulmonary hydatid cyst


1 Department of Trauma and Emergency Medicine, AIIMS, Bhubaneswar, Odisha, India
2 Department of General Surgery, AIIMS, Bhubaneswar, Odisha, India
3 Department of Anaesthesia, AIIMS, Bhubaneswar, Odisha, India

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Date of Submission24-Mar-2015
Date of Acceptance24-Apr-2016
Date of Web Publication6-Jul-2016
 

   Abstract 

Savlon (0.5% cetrimide/0.05% chlorhexidine) is used as a scolicidal during surgery of hydatid cysts. It is considered a safe and effective agent. However, there are no recommendations for the appropriate concentration or dosage of these agents. Previously reported to cause severe metabolic acidosis, its effects on the pulmonary system have not been explored. We present a case of acute lung injury and respiratory distress along with acute cardiopulmonary distress, severe metabolic acidosis, and renal failure following its use during surgical removal of pulmonary hydatid cyst. The agent may act as a chemical sclerosant causing pulmonary parenchymal damage through bronchial openings present in the pericyst. Till safe dose limits are known, use of this agent should be limited, especially in large or multiple cyst surgery.

Keywords: Acute lung injury; Hydatid cyst sclerosant; Metabolic acidosis; Renal failure; Savlon (0.5% cetrimide/0.05% chlorhexidine)

How to cite this article:
Tripathy S, Sasmal P, Rao P B, Mishra TS, Nayak S. Cetrimide-chlorhexidine-induced multiorgan failure in surgery of pulmonary hydatid cyst. Ann Card Anaesth 2016;19:557-60

How to cite this URL:
Tripathy S, Sasmal P, Rao P B, Mishra TS, Nayak S. Cetrimide-chlorhexidine-induced multiorgan failure in surgery of pulmonary hydatid cyst. Ann Card Anaesth [serial online] 2016 [cited 2019 Nov 19];19:557-60. Available from: http://www.annals.in/text.asp?2016/19/3/557/185565



   Introduction Top


Scolicidal agents are used to sterilize the cyst and prevent intraoperative dissemination of the parasite. Many agents have been recommended; savlon 10% a combination of 3% cetrimide w/v and chlorhexidine gluconate 1.5% w/v is commonly used. The low toxicity, rapid action against the protoscolices, and scolicidal effect at low concentration have been studied previously; there are no guidelines on the concentration and volume of the agent that can be used safely. [1],[2],[3],[4]

We present an interesting case report of a 25-year-old male patient operated for the removal of hepatic and pulmonary hydatid cysts, who developed acute renal failure, severe metabolic acidosis, shock, and acute lung injury due to cetrimide use, resulting in a protracted course in the Intensive Care Unit (ICU).


   Case report Top


Presenting concerns and clinical findings

A 25-year-old Indian male teacher presented with intermittent dull aching pain in the left chest for 1 month. The pain nonradiating in nature. There was no history of fever, cough with expectoration, loss of appetite, or recent weight loss. A nonsmoker without no addictions or animals contact. Only significant clinical finding was reduced air entry on the left basal region, with no localized tenderness.

Diagnostic focus and assessment

Blood investigations (hemogram, renal and liver function tests) were within normal limits. Chest X-ray showed a well-defined opacity in the left lower lobe [Figure 1]. Ultrasonogram of abdomen revealed a cystic lesion in the segment 8 of liver, suggestive of hydatid cyst. Computerized tomography (CT) scan of abdomen and thorax showed a 97 mm × 89 mm × 74 mm unilocular cystic lesion with enhancing peripheral walls in the left lower lobe of the lungs and 61 mm × 60 mm × 44 mm cyst in the segment VIII of liver abutting the diaphragm. Thin-walled daughter cysts were seen within the cyst [Figure 2]a and b.
Figure 1: Chest X-ray showing hydatid cyst in the left lower lobe

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Figure 2: (a and b) Computerized tomography scan image of the hydatid cysts in the lungs and liver

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Perioperative phase

The patient was advised oral albendazole 400 mg twice daily for 21 days continued for 8 weeks after surgery (excision of hepatic hydatid cyst followed by a left posterolateral thoracotomy for the pulmonary cyst).

Surgical procedure

Injection midazolam, ondansetron, and butorphanol were administered preoperatively as per protocol. Induction of anesthesia was with injection propofol 2 mg/kg and paralysis with injection vecuronium 6 mg. Anesthesia was maintained with isoflurane and nitrous oxide. The patient was intubated with 8.5 mm single lumen endotracheal tube fixed at 22 cm. Postinduction the right subclavian vein and right radial artery were cannulated.

Abdomen was explored by the right subcostal approach. Savlon (3% cetrimide - 1.5% chlorhexidine), diluted 1:1 with normal saline was used as scolicidal agent (20 ml in packs in the abdominal cavity and 40 ml to irrigate the cyst cavity). The cyst was sterilized by aspirating some fluid and replacing with scolicidal solution for 10 min. Partial pericystectomy and evacuation of the remaining daughter cysts and germinal membranes were done. The cavity was inspected for bile leak and closed with external drainage.

For the pulmonary cyst, aspiration was followed by instillation of 60 ml half strength savlon. After reaspiration of the pulmonary cyst contents, the pericyst was opened to evacuate the residual daughter cysts. Multiple bronchial openings revealed at this stage were meticulously suture closed, and the residual cyst cavity was obliterated by imbricating sutures from within (capitonnage technique). The incision was closed in layers with chest tube placed. The entire procedure lasted for 150 min.

Intraoperative events

During thoracotomy, patient developed tachycardia. Blood gas revealed severe metabolic acidosis with a pH/PaO 2 /PaCO 2 /base excess - 7.03/118/64/−10.8, respectively. Lactate was 1.8 mmol/L. Oxygenation deteriorated suddenly during irrigation of the cyst with scolicidal solution. Pink frothy secretions from the endotracheal tube and diffuse bilateral crepitation in the lung fields were noted. Ectopic beats and severe hypotension followed, requiring infusion of a high dose of adrenaline (0.2-0.5 U/min). Transthoracic ultrasonogram demonstrated bilateral B-lines with good left ventricular function suggesting noncardiogenic pulmonary edema.

Postoperative

The patient was shifted to the intensive care on vasopressors for ventilation. Nonoliguric renal failure (immediate postoperative serum creatinine1.8 mmol/dL and 2.4 mmol/dL on day 1) and severe metabolic acidosis (pH 7.1) normalized over 10 and 48 h, postoperatively. High-grade fever with normal white cell counts and sterile blood, urine, and endotracheal tube cultures was seen in early ICU stay. A diagnosis of chemical pneumonitis and acute respiratory distress syndrome (ARDS) was made based on the clinical (PaO 2 /FiO 2 <100 mmHg) and radiologic picture. This progressed over 4 days [Figure 3]a and b. PaO 2 /FiO 2 ratio improved from 60 to 150 over 10 days when the patient was extubated.

At 7 days of ICU discharge, the patient had tachypnea with residual pulmonary parenchymal changes on the CT scan suggestive of recovering acute lung injury [Figure 4]. At 1 month of follow-up, he was back to his preoperative state and doing well [Figure 5].
Figure 3: (a and b) Chest X-ray on day 1 and day 5 after the surgery showing bilateral diffuse fluffy opacities

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Figure 4: Computerized tomography scan taken 1 week after discharge from the Intensive Care Unit showing pulmonary parenchymal sequelae of acute lung injury - reticular shadows and ground glass appearance

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Figure 5: Chest X-ray at 1 month follow-up

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   Discussion Top


Our patient underwent a single-stage surgery for hepatic (segment VIII) and pulmonary (left lower lobe) hydatid cysts. He developed severe metabolic acidosis (pH 7.03) with normal serum lactate, hemodynamic instability, acute renal failure, and acute lung injury.

Hydatid cyst fluid being highly antigenic can cause anaphylactic shock. Key diagnostic features of anaphylaxis absent in our case were spillage of cyst fluid, cutaneous signs, angioedema, bronchospasm, generalized erythema, and raised serum lactate. Further, the stable body temperature and end-tidal gases ruled out malignant hyperthermia associated metabolic acidosis. Acute myocardial infarction or tension pneumothorax was similarly ruled out by table side transthoracic echocardiography.

To the best of our knowledge, the noncardiogenic pulmonary edema and ARDS are the first such reported events during the surgical excision of a pulmonary hydatid cyst. Larger pulmonary hydatid cysts (10 cm diameter) are associated with greater complications during surgery. [5] Bronchial openings in the pericystic cavity may allow entry of the scolicidal agent into the lung parenchyma resulting in severe chemical pneumonitis. The use of scolicidal agents in hepatic hydatid cyst disease (formaldehyde, hypertonic saline, etc.) are reported to cause sclerosing cholangitis in cysts with biliary duct communication and fibrosing peritonitis when used for peritoneal washout. [6],[7],[8] We postulate that cetrimide leaking into the parenchyma of bilateral lungs because of undetected cyst bronchial connection resulted in acute lung injury which progressed for the next few days and left radiologic sequelae even after discharge from the ICU. It is possible that the use of a double lumen endotracheal tube may have resulted in better protection of the contralateral lung; a double lumen tube, however, is associated with its own complications. [9],[10]

Stable total cell counts and culture negative tracheal aspirate ruled out an infectious etiology of ARDS. Recovery with steroids and protective lung ventilation ensued over 10 days.

Tested safe in animal studies, there are no recommendations for the upper limit of volume or concentration of cetrimide-chlorhexidine in human beings. [1],[2],[11] Complications have occurred with as low as 0.5% cetrimide and have included coma, hemolysis, and death. [12],[13],[14],[15] Metabolic acidosis and acute renal failure are known. [16],[17],[18] Puj and Chauhan reported having used 120 ml of 0.5% cetrimide during 2 h of surgery, resulting in delayed reversal, metabolic acidosis and nonoliguric renal failure needing ICU over 10 days. [16] Sathyanarayana et al. accept that the cause in their case might have been "liberal use" of cetrimide. [17] In our patient, the metabolic acidosis was detected immediately after the abdominal phase of the surgery, when the patient was hemodynamically stable, implicating cetrimide solution as the cause of the acute renal failure and acidosis in the background of normal serum lactates.


   Conclusion Top


Regulated volume and concentration of cetrimide-chlorhexidine solution are needed, especially in cases with large, multiple, or pulmonary cysts with possible bronchial communication. Anticipation of systemic complications and the use of double lumen tubes may be considered. Research on the safe limits of scolicidal agents used may be undertaken in the future.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Caglar R, Yuzbasioglu MF, Bulbuloglu E, Gul M, Ezberci F, Kale IT. In vitro effectiveness of different chemical agents on scolices of hydatid cyst. J Invest Surg 2008;21:71-5.  Back to cited text no. 1
    
2.
Frayha GJ, Bikhazi KJ, Kachachi TA. Treatment of hydatid cysts (Echinococcus granulosus) by cetrimide (R). Trans R Soc Trop Med Hyg 1981;75:447-50.  Back to cited text no. 2
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3.
Sonisik M, Korkmaz A, Besim H, Karayalçin K, Hamamci O. Efficacy of cetrimide-chlorhexidine combination in surgery for hydatid cyst. Br J Surg 1998;85:1277.  Back to cited text no. 3
    
4.
Ahrari H. Use of cetremide in the surgery of hydatid cysts. Bull Soc Pathol Exot Filiales 1978;71:90-4.  Back to cited text no. 4
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5.
Usluer O, Ceylan KC, Kaya S, Sevinc S, Gursoy S. Surgical management of pulmonary hydatid cysts: Is size an important prognostic indicator? Tex Heart Inst J 2010;37:429-34.  Back to cited text no. 5
    
6.
Momblano P, Pradere B, Jarrige N, Concina D, Bloom E. Metabolic acidosis induced by cetrimonium bromide. Lancet 1984;2:1045.  Back to cited text no. 6
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7.
Tozar E, Topcu O, Karayalcin K, Akbay SI, Hengirmen S. The effects of cetrimide-chlorhexidine combination on the hepato-pancreatico-biliary system. World J Surg 2005;29:754-8.  Back to cited text no. 7
    
8.
Abdalian R, Heathcote EJ. Sclerosing cholangitis: A focus on secondary causes. Hepatology 2006;44:1063-74.  Back to cited text no. 8
    
9.
Gupta R, Wadhawan S, Bhadoria P. Intraoperative endobronchial rupture of pulmonary hydatid cyst: An airway catastrophe. J Anaesthesiol Clin Pharmacol 2013;29:111-3.  Back to cited text no. 9
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10.
Esme H, Fidan H, Cekirdekci A. The problems and advantages of one lung ventilation during surgical intervention in pulmonary hydatid cyst disease. Indian J Thorac Cardiovasc Surg 2006;22:137-40.  Back to cited text no. 10
    
11.
Halezeroglu S, Okur E, Tanyü MO. Surgical management for hydatid disease. Thorac Surg Clin 2012;22:375-85.  Back to cited text no. 11
    
12.
Belghiti J, Perniceni T, Kabbej M, Fekete F. Complications of peroperative sterilization of hydatid cysts of the liver. Apropos of 6 cases. Chirurgie 1991;117:343-6.  Back to cited text no. 12
    
13.
Klouche K, Charlotte N, Kaaki M, Béraud JJ. Coma and haemolysis after cetrimide washout of epidural hydatid cyst. Intensive Care Med 1994;20:613.  Back to cited text no. 13
    
14.
Baraka A, Yamut F, Wakid N. Cetrimide-induced methaemoglobinaemia after surgical excision of hydatid cyst. Lancet 1980;2:88-9.  Back to cited text no. 14
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Bax NM, van der Zee DC, Turner NM, Rademaker CM, Gemke RJ. Cetrimide overdose. Surg Endosc 1997;11:967-9.  Back to cited text no. 15
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16.
Puj KS, Chauhan VF. Cetrimide induced metabolic acidosis: A rare intraoperative complication in a case of hydatid disease of liver. Int J Sci Res 2014;5:1492-5.  Back to cited text no. 16
    
17.
Sathyanarayana MV, Shenoy MG, Pai VM, Haque PW, Hegde P, Rajan R, et al. Metabolic acidosis induced by cetrimide-chlorhexidine solution in hydatid cyst surgery. Indian J Gastroenterol 1996;15:104.  Back to cited text no. 17
    
18.
Gilchrist DS. Chemical peritonitis after cetrimide washout in hydatid-cyst surgery. Lancet 1979;2:1374.  Back to cited text no. 18
    

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Correspondence Address:
Swagata Tripathy
Department of Trauma and Emergency Medicine, AIIMS, Dumduma, Sijua, Bhubaneswar - 751 019, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.185565

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

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1 Cetrimide/chlorhexidine
Reactions Weekly. 2016; 1615(1): 59
[Pubmed] | [DOI]



 

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