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LETTER TO THE EDITOR

Drug–Drug Interaction or a Local Anesthetic Overdose?

Kelowna, BC, Canada, angelmanguel{at}shaw.ca

To the Editor:

The case report by Marcucci et al. (1) elegantly describes cyotchrome P450 enzymes and their role in metabolizing various drugs significant in the practice of anesthesia. However, I believe they have concluded falsely that drug–drug interactions were primarily responsible for the cardiac arrest they reported. The patient in question clearly received an overdose of mepivacaine, which most likely accounted for cardiac depression and arrest. The maximum recommended dose (MRD) of mepivacaine in the adult is 400 mg (2). The patient on whom they reported received a total dose of 675 mg, 169% of the MRD administered in one bolus. In addition, although 15 µm of epinephrine was injected coincidentally, it is unlikely that this small amount of vascoconstrictor would counteract the potent vasodilating capabilities of mepivacaine. Hence, rapid uptake of an overdose of local anesthetic, rather than delayed metabolism as a result of drug interactions with P450 enzymes, was probably responsible for "causing unexpectedly high blood levels" of mepivacaine. However, it is notable that none of the panel detected the administration of an overdose of local anesthetic.

REFERENCES

1. Marcucci C, Sandson N, Thorn E, Bourke D. Unrecognized drug–drug interactions: a cause of intraoperative cardiac arrest? Anesth Analg 2006;102:1569–72.[Abstract/Free Full Text]
2. Saliras F, Liu S, Scholz A. Analgesics: ion channel ligands/sodium channel blockers/ local anesthetics. In: Evers A, Maze M, eds. Anesthetic pharmacology: physiologic principles and clinical practice. Philadelphia: Churchill Livingstone, 2004:507–38.

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