Chlorhexidine mediated access site ulceration.

Sir,

A 45-year-old female presented to our institution with an acute myocardial infarction. She required venoarterial extracorporeal membrane oxygenation (ECMO) and mechanical ventilation (for acute respiratory failure/pulmonary edema). Her hospital course was further complicated by sepsis, acute renal failure, and amputation of her right lower extremity secondary to a vascular insult that resulted from ECMO cannula placement. She had no known allergies. Here we report a rare case of serious skin ulceration secondary to a chemical burn produced by the antiseptic chlorhexidine (CHL) at the placement site of a central venous catheter.

The patient required central venous cannulation for fluids, inotropic/vasopressor support, monitoring, and renal dialysis. Her right and left internal jugular veins were accessed. Both catheters were removed and replaced in the same locations 1 week later when a fever occurred. Three days later, a necrotic ulcer was discovered at the hub of the right-sided internal jugular vein catheter [Figure 1]. Due to concerns for infection, the catheter was removed. The patient's access site had been treated with CHL at the time of each line placement and the dressing changed as per the intensive care unit protocol. The catheter tip was sent for culture, along with a small tissue sample from the ulcer. CHL use was discontinued because of a high index of suspicion regarding its etiology as the offending agent. Both cultures were reported as negative. Within 48 h the affected access site demonstrated substantial healing [Figure 2].

Figure 1

Chlorhexidine ulcer

Figure 2

Healing ulcer

CHL is a synthetic bisguanide that is a low cost, highly efficacious microbiocide commonly used in surgical fields. It can cause hypersensitivity reactions with resultant ulceration, and is an allergen that can cause anaphylaxis.[1] CHL's bactericidal capacity is unquestioned.[2] However, its ability to cause deleterious cytopathic effects on human cells in the laboratory is also well-documented.[3] Recent literature indicates that the type of chemical injury that occurred in our patient is underrecognized, especially in the very young, the critically ill, and the immunosuppressed.[4]

Whenever patients have dressings applied, whether they are CHL impregnated or simply a sterile dressing placed over an area of skin where a CHL scrub has been performed, there should be vigilant monitoring of the site.