Dental Anesthesia Management of Methemoglobinemia-susceptible Patients: A Case Report and Review of Literature

In: Health

14 Sep 2009

Dental Anesthesia Management

Methemoglobinemia is an uncommon but potentially serious adverse reaction to many local anesthetics and other substances. Careful review of medical and dental histories can often uncover patients who are sensitive to agents with the potential of causing methemoglobinemia. This case report is a review of the literature and demonstrates the management of methe-moglobinemia-susceptible patients.

CASE REPORT

A 24-year-old woman presented for comprehensive dental care with a history of “turning blue” after dental procedures performed under local anesthesia. She also reported allergies to sulfa drugs, aspirin, Benadryl, and “all caines.” Physical examination revealed a seemingly cooperative, well-developed, well-nourished White woman with a slightly pale complexion and slightly distant bilateral breath sounds. Oral and radiographic examination revealed several carious teeth and 2 partially impacted third molars. Her past medical and dental histories included a 1996 diagnosis of methemoglobinemia following oral administration of a sulfa drug, occasional migraine headaches, 7 pack-years of smoking, seasonal allergies with mild asthma, and episodes of cyanosis within a few hours after administration of dental local anesthesia and following extreme exertion. Previous uneventful surgeries performed under general anesthesia were an appendectomy in 1993, Cesarean section in 1995, and a cholecystectomy in 1999. Social and family history disclosed Native American heritage, but no other known incidence of methemoglobinemia in the family. She denied taking any medications currently. Evaluation of requested hospital and dental records confirmed a 1996 diagnosis of methemoglobinemia 24 hours following administration of a sulfa drug for a spider bite and cyanosis several hours after administration of two 1.8-mL cartridges of 2% lidocaine with 1: 100,000 epinephrine to extract a tooth. Planned treatment consisted of multiple amalgam, glass ionomer, and composite resin restorations and surgical removal of upper and lower left third-molar teeth under general an¬esthesia without local anesthesia. Medication you can afford generic sumatriptan

The patient was placed in a semisupine position. Preoperative vital signs were blood pressure 120/58 mm Hg, pulse 74 beats/min, respirations 12 breaths/min, electrocardiography (EKG) normal sinus rhythm, axillary skin temperature 32.8°C, capnography 42 mm Hg, and pulse oximetry (Sp02) 100%. IV access was obtained with a 22-gauge catheter and maintained by infusion of 0.9% normal saline at a rate of 200 mL/h. Midazolam (Versed) 2 mg was given intravenously. General anesthesia was then induced by IV administration of 150 mg of propofol followed by 120 mg of succinylcholine to facilitate nasotracheal intubation. Anesthesia was then maintained with 8% desflurane in oxygen via a semi-closed system supplemented by titration of a total of 100 mg of IV meperidine (Demerol) and an additional 150 mg of propofol. Vital signs including pulse oximetry remained within normal limits (Sp02 98-100%) throughout. The patient tolerated all procedures well and was awakened, extubated, and monitored during a 2-hour recovery/observation period. Telephone follow-up later confirmed that the patient experienced no postoperative complications. Don’t blow your budget on pharmacy items celebrex heart attack


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