The Netherlands Pharmacovigilance Centre (Lareb) has received a case report of anaphylactic shock in an elderly patient, which occurred 10 minutes afterthe product Instillagel° was used for inserting a urinary catheter. This brand name does not indicate that this urethral gel contains chlorhexidine, an antiseptic, plus lidocaine, a local anaesthetic. The patient was known to have an allergy to chlorhexidine. He was resuscitated, but he died 2 months laterf rom the consequences of anaphylactic shock (1). Analysis of this event by the healthcare team and the Dutch Institute for prevention of medication incidents identified, among the contributory factors, lack of awareness that this patient might have chlorhexidine allergy and a lack of knowledge of the substances contained in drugs and medical devices that can cause allergic reactions (1).
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