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ANESTHETIC PHARMACOLOGY

Methemoglobinemia Related to Local Anesthetics: A Summary of 242 Episodes

From the Department of Anesthesia, Maisonneuve-Rosemont Hospital, University of Montreal, Montreal Canada.

Address correspondence to Dr Joanne Guay, Department of Anesthesia, Maisonneuve-Rosemont Hospital, 5415 L'Assomption Boulevard, Montreal, Quebec, Canada H1T 2M4. Address e-mail to joanne.guay{at}umontreal.ca.

BACKGROUND: The purpose of this article is to summarize all episodes of local anesthetic-related methemoglobinemia found in the medical literature.

METHODS: I performed a search of the American National Library of Medicine's PubMed with the following key words: "local anesthetic" and "methemoglobinemia."

RESULTS: Two-hundred-forty-two episodes (40.1% published in year 2000 or after) were found. Chocolate-colored blood suggests methemoglobinemia but other colors may be found. A discrepancy between the pulse oximeter saturation (90%) and the arterial oxygen partial pressure (70 mm Hg) was present in 91.8% of the episodes. The difference between oxygen saturation measured by pulse oximetry and co-oximetry varied from –6.2% to 44.7%. Plain prilocaine may induce clinically symptomatic methemoglobinemia in children older than 6 mo at doses exceeding 2.5 mg/kg. In adults, the dose of prilocaine should be kept lower than 5.0 mg/kg, which is reduced to 3.2 mg/kg in the presence of renal insufficiency and to 1.3 mg/kg if other oxidizing drugs are used concurrently. A single spray of benzocaine may induce methemoglobinemia. Clinical symptoms may be observed at relatively low methemoglobin values, including coma at 32.2 and 29.1% in children and adults, respectively. Rebound methemoglobinemia (benzocaine on mucous membranes) with methemoglobin values as high as 59.9% may occur up to 18 h after methylene blue administration. Complications of methemoglobinemia include hypoxic encephalopathy, myocardial infarction, and death.

CONCLUSION: Benzocaine should no longer be used. Prilocaine should not be used in children younger than 6-mo-old, in pregnant women, or in patients taking other oxidizing drugs. The dose should be limited to 2.5 mg/kg.

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