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Prilocaine Induced Methemoglobinemia Güzelliğin Bedeli; Prilokaine Bağlı Gelişen Methemoglobinemi Olgusu

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Prilocaine Induced Methemoglobinemia Güzelliğin Bedeli; Prilokaine Bağlı Gelişen Methemoglobinemi Olgusu CASE REPORT 185 Cost of Beauty; Prilocaine Induced Methemoglobinemia Güzelliğin Bedeli; Prilokaine Bağlı Gelişen Methemoglobinemi Olgusu Elif KILICLI, Gokhan AKSEL, Betul AKBUGA OZEL, Cemil KAVALCI, Dilek SUVEREN ARTUK Department of Emergency Medicine, Baskent University Faculty of Medicine, Ankara SUMMARY ÖZET Prilocaine induced methemoglobinemia is a rare entity. In the pres- Prilokaine bağlı gelişen methemoglobinemi nadir görülen bir du- ent paper, the authors aim to draw attention to the importance of rumdur. Bu yazıda epilasyon öncesi kullanılan prilokaine sekonder this rare condition by reporting this case. A 30-year-old female gelişen methemoglobinemi olgusunu sunarak nadir görülen bu presented to Emergency Department with headache, dispnea and durumun önemine işaret etmek istiyoruz. Otuz yaşında kadın acil cyanosis. The patient has a history of 1000-1200 mg of prilocaine servise baş ağrısı, dispne ve siyanoz şikayetleri ile başvurdu. Hasta- ya beş saat öncesinde bir güzellik merkezinde epilasyon öncesinde subcutaneous injection for hair removal at a beauty center, 5 hours yaklaşık 1000-1200 mg prilokain subkutan enjeksiyonu yapıldığı ago. Tension arterial: 130/73 mmHg, pulse: 103/minute, body tem- öğrenildi. Başvuruda kan basıncı 130/73 mmHg, nabız 103/dk, vü- perature: 37 °C and respiratory rate: 20/minute. The patient had ac- cut ısısı 37 °C ve solunum sayısı 20/dk olarak kaydedilmişti. Hasta- ral and perioral cyanosis. Methemoglobin was measured 14.1% in nın akral siyanozu belirgindi. Venöz kan gazında methemoglobin venous blood gas test. The patient treated with 3 gr ascorbic acid düzeyi %14.1 olarak ölçüldü. Hastaya 3 g intravenöz askorbik asit intravenously. The patient was discharged free of symptoms after uygulandı. Tedavi sonrası semptomları gerileyen ve komplikasyon 48 hours of observation. Emergency physician should consider geliştirmeyen hasta 48 saat sonra taburcu edildi. Acil servis doktor- methemoglobinemia in presentation of dispnea and cyanosis after ları, prilokain enjeksiyonu sonrası gelişen dispne ve siyanoz ayırıcı injection of prilocaine. tanısında mutlaka methemoglobinemiyi akla getirmelidirler. Key words: Methemoglobinemia; prilocaine; cyanosis. Anahtar sözcükler: Methemoblobinemi; prilokain; siyanoz. Introduction tachycardia, hypotension, confusion, and even death can be seen in the more severe cases.[1] There are three common Hemoglobin (Hb) is a molecule which carries oxygen from causes of methemoglobinemia, including hemoglobinopa- respiratory organs to the rest of the body. Hb binds to iron thies, hereditary enzyme deficiencies (NADH MetHb reduc- in a ferrous (Fe2+) oxidation state under normal conditions. tase), and exposure to drugs. Interestingly, hemoglobin- However, the existence of oxidative stress is known to trans- opathies and hereditary enzyme deficiencies (NADH MetHb form iron to ferric iron (Fe3+). Upon oxidation, hemoglobin or reductase) are the least common causes, whereas exposure methemoglobin (MetHb) cannot bind to oxygen molecules. to drugs is the most common.[2] In methemoglobinemia, the Hb is unable to release oxygen effectively to body tissues. While mild forms of methemo- Many chemicals and drugs had been reported to cause toxic globinemia can be asymptomatic, cyanosis, tachypnea, methemoglobinemia, including nitrite, nitrate, chlorate, qui- Submitted: August 20, 2013 Accepted: November 11, 2013 Published online: January 17, 2014 Correspondence: Dr. Gökhan Aksel. Başkent Üniversitesi Tıp Fakültesi Ankara Hastanesi, Mareşal Fevzi Çakmak Mah., 10. Sokak, No: 45, Bahçelievler, Ankara, Turkey. e-mail: [email protected] Turk J Emerg Med 2014;14(4):185-187 doi: 10.5505/1304.7361.2014.79990 186 Turk J Emerg Med 2014;14(4):185-187 nine, aminobenzene, nitrobenzene, nitrotoluenes, phenac- the first step of treatment is to avoid further exposure. If etin, chloroquine, dapson, phenytoin, sulphonamides, and methemoglobinemia is under 20%, spontaneous recovery is local anesthetics.[3] Methemoglobinemia, caused by prilo- usually observed after drug avoidance, but treatment may caine a local anesthesia is rare.[4] Prilocaine, a derivative of be necessary in newborns and infants.[8] Methylene blue, toluidine, is an amide local anesthetic and has been shown ascorbic acid, and riboflavin have been suggested as treat- to produce high MetHb levels.[2,5] Because of its rarity, our ment modalities.[9] Methylene blue should be administered knowledge about treatment use is limited. In this paper, we 1-2 mg/kg intravenously in five minutes, and repeated one discuss a treatment strategy using ascorbic acid for a patient hour later if adequate improvement is not observed.[10] It is diagnosed with methemoglobinemia by prilocaine. Re- contraindicated in patients with glucose 6 phosphate dehy- search targets and strategies to understand best treatment drogenase deficiency because administration of methylene strategies will be discussed. blue can cause aggravation of methemoglobinemia, chest pain, cyanosis and hemolytic anemia.[3] In such cases, ascor- [11,12] Case Report bic acid can be considered as an antidote. Hyperbaric oxygen therapy and exchange transfusion is another option A 30-year-old woman was admitted to emergency depart- if MetHb level is over 70%. ment (ED) with complaints of tachycardia, headache, dys- pnea, and cyanosis. It was learned from her history that she Ascorbic acid reduces MetHb by a non-enzymatic processes was anesthetized with 2.5-3 vials (1000-1200 mg?) of prilo- in animal and human erythrocytes in vitro, which makes caine (citanest®) subcutaneously before a laser hair removal ascorbic acid a candidate for treatment of methemoglo- procedure. Although the severity of the symptoms de- binemia.[13,14] It is most commonly used orally in long term creased at the time of ED admission compared to the initial treatment of patients with hereditary methemoglobinemia. time point, her symptoms were still ongoing. The patient’s [1] Although, methylene blue can be a first choice treatment medical history was unremarkable. The tension arterial rate of methemoglobinemia, if there is limited experience in was 130/73 mmHg, pulse rate was 103/minute, body tem- the use of ascorbic acid in toxic methemoglobinemia.[15] Al- perature was 37 °C, and respiratory rate was 20/minute. The though MetHb was measured relatively less (14.1%) in the pulse oximeter measured O2 saturation as 90%, and she had present case, there was an indication of antidote therapy acral cyanosis. Electrocardiography revealed sinus tachycar- due to the patient being symptomatic. In addition, ascorbic dia with a rate of 103/minute. Chest radiograph, complete acid was chosen because a limited supply of methylene blue blood counting, renal function tests and electrolytes were in the hospital. After administration of ascorbic acid, MetHb all in the normal range. Venous blood gas analyses revealed was measured as 2.4% and she was asymptomatic. Aydogan MetHb as 14.1%. Despite treatment with 4 L/minute O2, her et al. reported that two patients with methemoglobinemia symptoms were still continual. She was admitted to the in- recovered after ascorbic acid administration.[13] Tekbas et al. tensive care unit and 3 grams of ascorbic acid was given in- also reported an improvement in a patient with combined travenously. Two hours after treatment, control MetHb was treatment of methylene blue and ascorbic acid caused by measured as 2.4%, and the patient was free of symptoms methemoglobinemia due to prilocaine given before intra- and with no complications. She was discharged as healthy vascular laser therapy.[16] upon a 48 hour of follow up period. Conclusion Discussion Methemoglobinemia resulting from the usage of prilocaine Prilocaine at therapeutic doses (1-2 mg/kg) can cause lim- within and out of hospital is a major concern. Methemoglo- ited methemoglobinemia without cyanosis.[6] The maximum binemia should be considered in patients who had cyanosis safe dose of prilocaine is 8 mg/kg (maximum of 600 mg) as after local anesthetic administration. In cases which methy- a single injection.[2] In this case, 1000-1200 mg of prilocaine lene blue could not be used as an antidote, ascorbic acid can was administered, in which the limits were highly exceeded. be a safe alternative. The effects of local anesthetic induced methemoglobinemia Conflict of Interest are known and include seizures, respiratory compromise, myocardial infarction, shock state, coma, hypoxic encepha- The authors declare that there is no potential conflicts of in- lopathy, and death. In a retrospective study it was reported terest. that most patients with a methemoglobin (≥8%) were symp- tomatic.[7] References In methemoglobinemia resulting from chemical substances, 1. Honig GR. Hemoglobin disorder. In: Behrman RE, Kleigman Kilicli E et al. Cost of Beauty 187 RM, Jenson HB, editors. Nelson textbook of pediatrics. Phila- 10. Ryoo S, Sohn Ch, Oh B, Kim W, Lim K. A case of severe methe- delpiha: Saunders; 2004. p. 1478-88. moglobinemia caused by hair dye poisoning. Hum Exp Toxi- 2. Aygencel SG, Akinci E, Pamukcu G. Prilocaine induced methe- col 2014;33:103-5. CrossRef moglobinemia. Saudi Med J 2006;27:111-3. 11. Gülgün M, Kul M, Sarıcı S. Prilocaine-induced methemoglo- 3. Tabel Y, Sandikkaya A, Gungor S, Ozgen U. Methemoglobin- binemia: report of two cases and review of literature. Erciyes emia after injection of prilocaine for pre-medication of cir- Tıp Dergisi (Erciyes Medical Journal) 2007;29:322-5. cumcision. [Article in Turkish] J Dicle Med School 2009:36:53-
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