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Endoscopy 2002; 34(9): 730-734
DOI: 10.1055/s-2002-33450
Case Report

© Georg Thieme Verlag Stuttgart · New York

Methemoglobinemia Induced by Topical Benzocaine: A Warning for the Endoscopist

H.  Y.  Abdallah1 , S.  A.  Shah1
  • 1Memorial Hospital of Rhode Island, Brown Medical School, Providence, Rhode Island, USA
Further Information

Publication History

Submitted: 18 May 2001

Accepted after Revision: 17 April 2002

Publication Date:
26 August 2002 (online)

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Benzocaine is used routinely for topical pharyngeal anesthesia prior to upper endoscopy, to improve patient tolerance. A potentially fatal, although often unrecognized, complication of benzocaine use is methemoglobinemia. Here, we report a case of methemoglobinemia induced by benzocaine given before upper endoscopy. Rapid recognition of this complication and immediate treatment is essential to prevent complications related to significant tissue hypoxia. This case serves as an important reminder to physicians, especially endoscopists, about this serious side effect. Furthermore, we question the need for topical anesthesia for upper endoscopy in sedated patients.

References

  • 1 Collins J F. Methemoglobinemia as a complication of 20 % benzocaine spray for endoscopy.  Gastroenterology. 1990;  98 211-213
    PubMedGoogle Scholar
  • 2 Dinneen S F, Mohr D N. Fairbanks VF. Methemoglobinemia from topically applied anesthetic spray.  Mayo Clin Proc. 1994;  69 886-888
    PubMedGoogle Scholar
  • 3 Bernstein S C, Bowman J E, Noche L K. Interaction of sickle cell trait and glucose-6-phosphate dehydrogenase deficiency in Cameroon.  Hum Hered. 1980;  30 7-11
    PubMedGoogle Scholar
  • 4 Metz E N, Balcerzak P, Sagone, Jr A L. Mechanisms of methylene blue stimulation of the hexose monophosphate shunt in erythrocytes.  J Clin Invest. 1976;  58 797-802
    PubMedGoogle Scholar
  • 5 Ashmun R A, Hultquist D E, Schultz J S. Kinetic analysis in single, intact cells by microspectrophotometry: Evidence for two populations of erythrocytes in an individual heterozygous for glucose-6-phosphate dehydrogenase deficiency.  Am J Hematol. 1986;  23 311-316
    PubMedGoogle Scholar
  • 6 Benatti U, Guida L, Grasso M. et al . Hexose monophosphate shunt-stimulated reduction of methemoglobin by divicine.  Arch Biochem Biophys. 1985;  242 549-556
    CrossrefPubMedGoogle Scholar
  • 7 Jaffe E R. Enzymopenic hereditary methemoglobinemia: A clinical/biochemical classification.  Blood Cells. 1986;  12 81-90
    PubMedGoogle Scholar
  • 8 Zinkham W H, Oski F A. Henna: A potential cause of oxidative hemolysis and neonatal hyperbilirubinemia.  Pediatrics. 1996;  97 707-709
    PubMedGoogle Scholar
  • 9 Anderson S T, Hajduczek J Barker. Benzocaine-induced methemoglobinemia in an adult: Accuracy of pulse oximetry with methemoglobinemia.  Anesth Analg. 1988;  67 1099-1101
    PubMedGoogle Scholar
  • 10 Buckley A B, Newman A. Methemoglobinemia occurring after the use of a 20 % benzocaine topical anesthetic prior to gastroscopy.  Gastrointest Endosc. 1987;  33 466-467
    PubMedGoogle Scholar
  • 11 Ellis F D, Seiler J G 3rd, Palmore M M, Jr. Methemoglobinemia: A complication after fiberoptic orotracheal intubation with benzocaine spray. A case report.  J Bone Joint Surg Am. 1995;  77 937-939
    PubMedGoogle Scholar
  • 12 O'Donohue W J , Moss L M, Angelillo V A. Acute methemoglobinemia induced by topical benzocaine and lidocaine.  Arch Intern Med. 1980;  140 1508-1509
    CrossrefPubMedGoogle Scholar
  • 13 Scott E, Hoskins D D. Hereditary methemoglobinemia in Alaskan Eskimos and Indians.  Blood. 1958;  13 759-802
    PubMedGoogle Scholar
  • 14 Douglas W W, Fairbanks V F. Methemoglobinemia induced by a topical anesthetic spray (cetacaine).  Chest. 1977;  71 (5) 587-591
    PubMedGoogle Scholar
  • 15 Brown C M, Levy S A, Susann P W. Methemoglobinemia: Life-threatening complication of endoscopy premedication.  Am J Gastroenterol. 1994;  89 1108-1109
    PubMedGoogle Scholar
  • 16 Ferraro L, Zeichner S, Greenblott G. et al . Cetacaine-induced acute methemoglobinemia.  Anesthesiology. 1988;  69 (4) 614-615
    PubMedGoogle Scholar
  • 17 Grum D F, Rice T W. Methemoglobinemia from topical benzocaine.  Cleve Clin J Med. 1990;  57 357-359
    PubMedGoogle Scholar
  • 18 Jackson S L. Reversing methemoglobinemia.  Nursing. 1992;  22 33
    PubMedGoogle Scholar
  • 19 Klein S L, Nustad R A, Feinberg S E. et al . Acute toxic methemoglobinemia caused by a topical anesthetic.  Pediatr Dent. 1983;  5 107-108
    PubMedGoogle Scholar
  • 20 Peterson H. Acquired methemoglobinemia in an infant due to benzocaine suppository.  N Engl J Med. 1960;  263 454-455
    PubMedGoogle Scholar
  • 21 Wright R O, Lewander W J, Woolf A D. Methemoglobinemia: Etiology, pharmacology, and clinical management.  Ann Emerg Med. 1999;  34 646-656
    CrossrefPubMedGoogle Scholar
  • 22 Smith R P, Olson M V. Drug-induced methemoglobinemia.  Semin Hematol. 1973;  10 253-268
    PubMedGoogle Scholar
  • 23 Barker S J, Tremper K K, Hyatt J. Effects of methemoglobinemia on pulse oximetry and mixed venous oximetry.  Anesthesiology. 1989;  70 112-117
    PubMedGoogle Scholar
  • 24 Eisenkraft J B. Pulse oximeter desaturation due to methemoglobinemia.  Anesthesiology. 1988;  68 279-282
    PubMedGoogle Scholar
  • 25 Mathews P J . Co-oximetry.  Respir Care Clin N Am. 1995;  1 47-68
    PubMedGoogle Scholar
  • 26 Curry S. Methemoglobinemia.  Ann Emerg Med. 1982;  11 214-221
    CrossrefPubMedGoogle Scholar
  • 27 Wintrobe M. Methemoglobinemia and other disorders usually accompanied by cyanosis.  Clinical Hematology. Philadelphia; Lea & Febiger 1981: 1011-1018
    Google Scholar
  • 28 Harrison M R. Toxic methaemoglobinaemia. A case of acute nitrobenzene and aniline poisoning treated by exchange transfusion.  Anaesthesia. 1977;  32 270-272
    PubMedGoogle Scholar
  • 29 Tingle M D, Coleman M D, Park B K. An investigation of the role of metabolism in dapsone-induced methaemoglobinaemia using a two compartment in vitro test system.  Br J Clin Pharmacol. 1990;  30 829-838
    PubMedGoogle Scholar
  • 30 Reigart J R, Trammel H L, Lindsey J M. Repetitive doses of activated charcoal in dapsone poisoning in a child.  J Toxicol Clin Toxicol. 1982;  19 1061-1066
    PubMedGoogle Scholar
  • 31 Wright R O, Magnani B, Shannon M W. et al . N-acetylcysteine reduces methemoglobin in vitro.  Ann Emerg Med. 1996;  28 499-503
    CrossrefPubMedGoogle Scholar
  • 32 Wright R O, Woolf A D, Shannon M W. et al . N-acetylcysteine reduces methemoglobin in an in vitro model of glucose-6-phosphate dehydrogenase deficiency.  Acad Emerg Med. 1998;  5 225-229
    PubMedGoogle Scholar
  • 33 Guant D BD, Green R A. Clinicopathologic evaluation of N-acetylcysteine in acetaminophen toxicosis in the cat.  Am J Vet Res. 1981;  42 1982-1984
    PubMedGoogle Scholar
  • 34 Campo R, Brullet E, Montserrat A. et al . Topical pharyngeal anesthesia improves tolerance of upper gastrointestinal endoscopy: A randomized doubleblind study.  Endoscopy. 1995;  27 659-664
    PubMedGoogle Scholar
  • 35 Froehlich F, Schwizer W, Thorens J. et al . Conscious sedation for gastroscopy: Patient tolerance and cardiorespiratory parameters.  Gastroenterology. 1995;  108 697-704
    CrossrefPubMedGoogle Scholar
  • 36 Chuah S Y, Crowson C P, Dronfield M W. Topical anaesthesia in upper gastrointestinal endoscopy.  Br Med J. 1991;  303 695
    PubMedGoogle Scholar
  • 37 Cantor D S, Baldridge E T. Premedication with meperidine and diazepam for upper gastrointestinal endoscopy precludes the need for topical anesthesia.  Gastrointest Endosc. 1986;  32 339-341
    CrossrefPubMedGoogle Scholar

S. A. Shah, M.D.

Gastroenterology Associates

One Randall Square · Providence · RI 02904 · USA ·

Fax: + 1-401-454-0410

Email: samirs@brown.edu

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