In this case report, we describe a healthy urological patient who suffered severe intraoperative anaphylaxis to chlorhexidine, an ingredient contained in frequently used lubricants (Instillagel®, Endosgel®). Chlorhexidine is a well-known skin disinfectant and antiseptic component in mouthwash or other over the counter antiseptic pharmaceuticals. There is little awareness that commonly used lubricants may contain hidden chlorhexidine. After severe intraoperative anaphylaxis, it is important to investigate all potential (including hidden) agents that might have caused this life-threatening reaction.
From the *Institute of Anesthesiology and Pain Medicine, and †Department of Urology, Kantonsspital Winterthur, Winterthur, Switzerland.
Accepted for publication July 17, 2013.
Funding: The study was supported by departmental funds.
The authors declare no conflicts of interest.
Address correspondence to Michael T. Ganter, MD, Institute of Anesthesiology and Pain Medicine, Kantonsspital Winterthur, Brauerstrasse 15, CH-8401 Winterthur, Switzerland. Address e-mail to email@example.com.