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Severe methemoglobinemia from topical anesthetic spray: case report, discussion and qualitative systematic review

Published online by Cambridge University Press:  21 May 2015

Riyad B. Abu-Laban*
Affiliation:
The Department of Emergency Medicine, Vancouver General Hospital, Vancouver, BC
Peter J. Zed
Affiliation:
The Department of CSU Pharmaceutical Sciences, Vancouver General Hospital, Vancouver, BC
Roy A. Purssell
Affiliation:
The Department of Emergency Medicine, Vancouver General Hospital, Vancouver, BC
Kenneth G. Evans
Affiliation:
The Department of Thoracic Surgery, Vancouver General Hospital, Vancouver, BC
*
Department of Emergency Medicine, Vancouver General Hospital, 855 W 12th Ave., Vancouver BC V5Z 1M9; [email protected]

Abstract

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Few health care professionals realize that topical anesthetic spray can cause methemoglobinemia. We describe a 56-year-old woman who was transferred to our emergency department when severe cyanosis and chest pain developed after administration of topical oropharyngeal benzocaine and lidocaine during outpatient endoscopy. Investigations revealed a methemoglobin level of 51%. Despite rapid diagnosis and treatment with methylene blue, pulmonary edema consistent with adult respiratory distress syndrome developed, endotracheal intubation was required, and the patient suffered a lengthy course in the intensive care unit. This article presents a detailed discussion of the pathophysiology, diagnosis and treatment of methemoglobinemia, as well as a qualitative systematic review of the English literature on methemoglobinemia induced by topical anesthetic. The implications of this condition for emergency physicians are also outlined.

Type
Case Report • Observations
Copyright
Copyright © Canadian Association of Emergency Physicians 2001

References

1.Curry, A, Carlton, M.Hemotologic consequences of poisoning. In: Haddad, LM, Shannon, MW, Winchester, JF, editors. Clinical management of poisoning and overdose, 3rd ed. Philadelphia: WB Saunders; 1998. p. 22335.Google Scholar
2.Watcha, MF, Connor, MT, Hing, AV.Pulse oximetry and methemoglobinemia. AJDC 1989;143:8457.Google ScholarPubMed
3.Barker, SJ, Tremper, SJ, Hyatt, J, Zaccari, J.Effects of methemoglobinemia on pulse oximetry and mixed venous oximetry. Anesthesiol 1987;67(3A):A171.Google Scholar
4.Howland, MA.Antidotes in depth: methylene blue. In: Goldfrank, LR.Goldfrank’s toxocologic emergencies, 5th ed. Norwalk: Appleton and Lange; 1994. p. 117980.Google Scholar
5.Blanc, PD.Methemoglobinemia. In: Olson, KR, editor. Poisoning and drug overdose, 3rd ed. Norwalk: Appleton & Lange; 1999. p. 2179.Google Scholar
6.Fisher, MA, Henry, D, Gillam, L, Chen, C.Toxic methemoglobinemia: a rare but serious complication of transesophageal echocardgiography. Can J Cardiol 1998;14:115760.Google Scholar
7.Malhotra, S, Kolda, M, Nanda, NC.Local anesthetic-induced methemoglobinemia during transesophageal echocardiography. Echocardiography 1998;15:1657.CrossRefGoogle ScholarPubMed
8.Ho, RT, Nanevicz, T, Yee, R, Figueredo, VM.Benzocaine-induced methemoglobinemia: two case reports related to transesophageal echocardiography premedication. Cardiovasc Drugs Ther 1998; 12:2112.CrossRefGoogle ScholarPubMed
9.Maher, P.Methemoglobinemia: an unusual complication of topical anesthesia. Gastroenterol Nurs 1998;21:1735.CrossRefGoogle ScholarPubMed
10.Clary, B, Skaryak, L, Tedder, M, Hilton, A, Botz, G, Harpole, D.Methemoglobinemia complicating topical anesthesia during bronchoscopic procedures. J Thorac Cardiovasc Surg 1997;114: 2935.CrossRefGoogle ScholarPubMed
11.Cooper, HA.Methemoglobinemia caused by benzocaine topical spray. South Med J 1997;90:9468.CrossRefGoogle ScholarPubMed
12.Guerriero, SE.Methemoglobinemia caused by topic benzocaine. Pharmacotherapy 1997;17:103840.CrossRefGoogle Scholar
13.Ferraro-Borgida, MJ, Mulhern, SA, DeMeo, MO, Bayer, MJ.Methemoglobinemia from perineal application of anesthetic cream. Ann Intern Med 1997;27:7858.Google Scholar
14.Gilman, CS, Veser, FH, Randall, D.Methemoglobinemia from topical oral anesthetic. Acad Emerg Med 1997;4:10113.Google ScholarPubMed
15.Shua-Haim, JR, Wyszkowski, R, Gross, JS.Unusual case of methemoglobinemia in an elderly patient following topical spray of benzocaine. Clin Geriatr 1996;4:7885.Google Scholar
16.Grauer, SE, Girard, GD.Toxic methemoglobinemia after topic anesthesia for transesophageal echocardiography. J Am Soc Echocardiogr 1996;9:8746.CrossRefGoogle Scholar
17.Lee, E, Boorse, R, Marcinczyk, M.Methemoglobinemia secondary to benzocaine topical anesthetic. Surg Laparosc Endosc 1996; 6:4923.CrossRefGoogle ScholarPubMed
18.Ellis, FD, Seiler, JG, Palmore, MM.Methemoglobinemia: a complication after fiberoptic orotracheal intubation with benzocaine spray. J Bone Joint Surg 1995;77:9379.CrossRefGoogle ScholarPubMed
19.Brown, CM, Levy, SA, Susann, PW.Methemoglobinemia: life-threatening complication of endoscopy premedication. Am J Gastroenterol 1994;89:11089.Google ScholarPubMed
20.Dinneen, SF, Mohr, DN, Fairbanks, VF.Methemoglobinemia from topically applied anesthetic spray. Mayo Clin Proc 1994; 69:8868.CrossRefGoogle ScholarPubMed
21.Rodriguez, LF, Smolik, LM, Zbehlik, AJ.Benzocaine-induced methemoglobinemia: report of a severe reaction and review of the literature. Ann Pharmacother 1994;28:6439.CrossRefGoogle ScholarPubMed
22.Vessely, MB, Zitsch III, RP.Topical anesthetic-induced methemoglobinemia: a case report and review of the literature. Otolaryngol Head Neck Surg 1993;108:7637.CrossRefGoogle ScholarPubMed
23.Muchmore, EA, Dahl, BJ.One blue man with mucositis. N Engl J Med 1992;327:133.Google ScholarPubMed
24.Marcovitz, PA, Williamson, B, Armstrong, WF.Toxic methemoglobinemia caused by topical anesthetic given before transesophageal echocardiography. J Am Soc Echocardiogr 1991;4:6158.CrossRefGoogle ScholarPubMed
25.Linares, LA, Peretz, TY, Chin, J.Methemoglobinemia induced by topical anesthetic (benzocaine). Radiother Oncol 1990;18:2679.CrossRefGoogle ScholarPubMed
26.Collins, JF.Methemoglobinemia as a complication of 20% ben-zocaine spray for endoscopy. Gastroenterol 1990;98:2113.CrossRefGoogle Scholar
27.Grum, DF, Rice, TW.Methemoglobinemia from topical benzocaine. Cleve Clin J Med 1990;57:3579.CrossRefGoogle ScholarPubMed
28.Kotler, R, Hansen-Flaschen, J, Casey, MP.Severe methemoglobinemia after flexible fibreoptic bronchoscopy. Thorax 1989; 44:2345.CrossRefGoogle ScholarPubMed
29.Ferraro, L, Zeichner, S, Greenblott, G, Groeger, JS.Cetacaineinduced acute methemoglobinemia. Anesthesiology 1988;69: 6145.CrossRefGoogle ScholarPubMed
30.Anderson, ST, Hajduczek, J, Barker, SJ, Benzocaine-induced methemoglobinemia in an adult: accuracy of pulse oximetry with methemoglobinemia. Anesth Analg 1988;67:1099101.Google Scholar
31.Buckley, AB, Newman, A.Methemoglobinemia occurring after the use of 20% benzocaine topical anesthetic spray prior to gastroscopy. Gastrointest Endosc 1987;33:4667.CrossRefGoogle Scholar
32.Speilman, FJ, Anderson, JA, Terry, WC.Benzocaine-induced methemoglobinemia during general anesthesia. J Oral Maxillo Surg 1984;42:7403.CrossRefGoogle Scholar
33.Olson, ML, McEvoy, GK.Methemoglobinemia induced by local anesthetics. Am J Hosp Pharm 1981;38:8993.Google ScholarPubMed
34.Sandza, JG, Roberts, RW, Shaw, RC, Connors, JP.Symptomatic methemoglobinemia with a commonly used topical anesthetic spray. Ann Thorac Surg 1980;30:18790.CrossRefGoogle Scholar
35.O’Donohue, WJ, Moss, LM, Angelillo, VA.Acute methemoglobinemia induced by topical benzocaine and lidocaine. Arch Inten Med 1980;140:15059.Google Scholar
36.Douglas, WW, Fairbanks, VF.Methemoglobinemia induced by a topical anesthetic spray (cetacaine). Chest 1977;71:58791.Google Scholar
37.Khan, NA, Kruse, JA.Methemoglobinemia induced by topical anesthesia: a case report and review. Am J Med Sci 1999;318: 4158.Google Scholar
38.Slaughter, MS, Gordon, PJ, Roberts, JC, Pappas, PS.An unusual case of hypoxia from benzocaine-induced methemoglobinemia. Ann Thorac Surg 1999;67:17768.CrossRefGoogle ScholarPubMed
39.Nguyen, ST, Cabrales, RE, Bashour, A, Rosenberger, TE, Michener, JA, Yared, J-P, Starr, NJ.Benzocaine-induced methemoglobinemia. Anesth Analg 2000;90:36771.CrossRefGoogle ScholarPubMed
40.Wurdeman, RL, Mohiuddin, SM, Holmberg, MJ, Shalaby, A.Benzocaine-induced methemoglobinemia during and outpatient procedure. Pharmacotherapy 2000;20:7358.CrossRefGoogle ScholarPubMed
41.Gupta, PM, Lala, DS, Arsura, EL.Benzocaine-induced methemoglobinemia. South Med J 2000;93:836.CrossRefGoogle ScholarPubMed
42.Haynes, JM.Acquired methemoglobinemia following benzocaine anesthesia of the pharynx. Am J Crit Care 2000;9:199201.CrossRefGoogle ScholarPubMed