Anaphylactic Shock to Intravenous Indocyanine Green During a Robotic Right Colectomy

Intravenous indocyanine green (IV ICG) is regarded as a safe immunofluorescence agent used to assess bowel perfusion prior to creating bowel anastomoses and aids in ureter identification during intra-abdominal surgery. We report the first instance of anaphylactic shock to IV ICG after prior toleration of ICG via an intra-ureteral route. Shortly after administering IV ICG, our patient became hypotensive and hypoxic requiring chest compressions, vasoactive medications, and thoracostomy tubes prior to identifying the symptoms as an allergic reaction. Anaphylaxis is not a recognized side effect of ICG and was not immediately considered. As ICG becomes increasingly utilized as an immunofluorescence agent among surgical specialties, increased awareness and recognition of anaphylactic shock as a potential side effect of ICG may lead to expedited diagnoses, treatment, and more critical evaluation of indications for future use. Additionally, our patient first tolerated intra-ureteral administration without a systemic reaction, suggesting a possible sensitization mechanism.