Hostname: page-component-cd9895bd7-7cvxr Total loading time: 0 Render date: 2024-12-26T18:36:26.581Z Has data issue: false hasContentIssue false
  • English
  • Français

Risk factors for prilocaine-induced methaemoglobinaemia following peripheral regional anaesthesia

Published online by Cambridge University Press:  24 May 2006

F. G. Vasters ,
L. H. J. Eberhart ,
T. Koch ,
P. Kranke ,
H. Wulf  and
A. M. Morin
F. G. Vasters
Affiliation:
Philipps-University Marburg, Department of Anaesthesiology and Critical Care Medicine, Marburg, Germany
L. H. J. Eberhart
Affiliation:
Philipps-University Marburg, Department of Anaesthesiology and Critical Care Medicine, Marburg, Germany
T. Koch
Affiliation:
Philipps-University Marburg, Department of Anaesthesiology and Critical Care Medicine, Marburg, Germany
P. Kranke
Affiliation:
University of Würzburg, Department of Anaesthesiology, Würzburg, Germany
H. Wulf
Affiliation:
Philipps-University Marburg, Department of Anaesthesiology and Critical Care Medicine, Marburg, Germany
A. M. Morin
Affiliation:
Philipps-University Marburg, Department of Anaesthesiology and Critical Care Medicine, Marburg, Germany
Get access

Abstract

Summary

Background: The local anaesthetic prilocaine has a low systemic toxicity mainly because of a high absorption in the lung and a large volume of distribution and thus is associated with a lower risk of neurological or cardiac side-effects. However, the major disadvantage is the formation of methaemoglobin by its metabolite o-toluidine. This prospective observational study was performed to identify factors that are associated with increased prilocaine-induced methaemoglobinaemia. Patients and methods: One Hundred and sixty two patients undergoing major knee surgery under general anaesthesia combined with peripheral nerve blocks (femoral nerve block, combined femoral/sciatic nerve block or lumbar plexus block) received a single bolus injection of 300 or 400 mg prilocaine about 30 min before surgery via a catheter. The proper placement was verified using nerve stimulation via a stimulating catheter. Three hours after prilocaine injection, venous blood samples were drawn and methaemoglobin levels were measured by standard photometric technique. Data was subjected to a stepwise multiple regression analysis. Results: The mean methaemoglobin for all patients was 2.7% (range: 0.9–15.4%). A higher dose of prilocaine and younger age were the most important predictive factors for higher methaemoglobin formation. Female sex and to a lesser extent the use of high-concentration/low-volume prilocaine also increased methaemoglobin levels. These four factors of the model explain 36% of the total variance. Other investigated factors, including the patient’s height, weight, body mass index, the site of catheter insertion, the anaesthetist’s judgement concerning the difficulty of catheter placement, duration of catheter placement or an inadvertent puncture of a venous or arterial vessel, had no significant impact on the concentration of methaemoglobin. Conclusion: The use of prilocaine for regional block is safe, since the older patients who might be more susceptible to suffer from clinical symptoms of methaemoglobinaemia usually form less methaemoglobin. However, since prediction of high methaemoglobin levels is difficult, anaesthesiologists performing regional blocks in patients who might be jeopardized by a decreased oxygen transport capacity should avoid high doses of prilocaine.

Keywords

ANAESTHETICS LOCAL, prilocaineANAESTHESIA, CONDUCTIONSURGERY, kneeMETHAEMOGLOBINAEMIA
Type
Original Article
Information
European Journal of Anaesthesiology , Volume 23 , Issue 9 , September 2006 , pp. 760 - 765
Copyright
2006 European Society of Anaesthesiology

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Scott DB, Cousins MJ. Clinical pharmacology of local anesthetic agents. In: Cousins MJ, Bridenbaugh PO, eds. Neural Blockade in Clinical Anesthesia and Management of Pain.Philadelphia: JB Lippincott, 1988: 115–119.
Zink W, Graf BM. Toxikologie der Lokalanästhetika. Anaesthesist 2003; 52: 1102–1123.Google Scholar
Scott DB, Jebson P, Braid B. Factors affecting plasma levels of lignocaine and prilocaine. Br J Anaesth 1972; 44: 1040–1049.Google Scholar
Löfström JB. Physiologic disposition of local anesthetics. Reg Anaesth 1982; 7: 33–38.Google Scholar
Kaiser H, Niesel HC, Biscoping J, al Rafai S, Klimpel L. Plasma prilocaine and mepivacaine concentrations after combined lumbosacral plexus block. Acta Anaesth Scand 1992; 36: 689–691.Google Scholar
Eifert B, Hahn R, Maier B, Konrad F, Georgieff M. Die kombinierte ‘3-in-1’/Ischiadicus-Blockade. Blockadeerfolg, serumspiegel und nebenwirkungen bei einsatz von je 700 mg mepivacain 1% ohne und mit adrenalin sowie prilocain 1%. Anaesthesist 1996; 45: 52–58.Google Scholar
Tryba M, Kurth H, Zenz M. Klinische und toxikologische untersuchung zur axillären plexusblockade mit prilocain oder mepivacain. Reg Anaesth 1987; 10: 31–36.Google Scholar
Rudlof B, Durstewitz-Knierim D, Ridderskamp I, Scharenberg C, Brandt L. Verstärkung der prilocain-induzierten methamoglobinämie durch narkoseeinleitung? Anaesthesist 1995; 44: 445–449.Google Scholar
Kortgen A, Janneck U, Vetsch A, Bauer M. Methamoglobinämie durch prilocain nach plexusanästhesien. Reduktion durch prophylaktische gabe von ascorbinsäure. Anaesthesist 2003; 52: 1020–1026.Google Scholar
Dumont L, Mardirosoff C, Dumont C, Mattys M, Massaut J. Methaemoglobinemia induced by a low dose of prilocaine during interscalenic block. Acta Anaesthesiol Belg 1995; 46: 39–42.Google Scholar
Nolte H, Dudeck J, Hultzsch B. Untersuchungen über die dosisabhängigkeit der methämoglobinbildung bei anwendung von prilocain (Citanest). Anaesthesist 1968; 17: 343–346.Google Scholar
Wagner F, Taeger L. Kombinierter ischiadikus/3-in-1block. III. Prilocain 1% versus mepivacain 1%. Reg Anaesth 1988; 11: 61–64.Google Scholar
White CD, Weiss LD. Varying presentations of methemoglobinemia: two cases. J Emerg Med 1991; 9 (Suppl 1): 45–49.Google Scholar
Sall JP. Leverage plots for general linear hypothesis. Am Stat 1990; 44: 303–315.Google Scholar
Rudlof B, Lampert R, Brandt L. Untersuchungen zum einsatz der pulsoxymetrie bei prilocaininduzierter methamoglobinämie. Anaesthesist 1995; 44: 887–891.Google Scholar
Wagner F, Missler B. Kombinierter ischiadikus/3-in-1-block. Prilocain 500 mg vs. 650 mg. Anaesthesist 1997; 46: 195–200.Google Scholar
Tryba M, Borner P. Klinische wirksamkeit und systemtoxizität verschiedener mischungen von prilocain und bupivacain zur axillären plexusblockade. Reg Anaesth 1988; 11: 40–49.Google Scholar
Tryba M, Hausmann E, Zenz M, Wellhoner HH. Toxizität von prilocain und bupivacain in der intravenösen regionalanästhesie. Anasth Intensivther Notfallmed 1982; 17: 207–210.Google Scholar
Löfgren N, Tegner C. Studies on local anesthetics.XX. Synthesis of some a-mono-alkylamin-2-methylpropion-anilines. Acta Chem Scand 1960; 14: 486–490.Google Scholar
Sadove M, Jobgen EA, Heller FN, Rosenberg R. Methemoglobinemia – an effect of a new local anesthetic, L-67 (prilocaine). Acta Anaesthesiol Scand Suppl 1965; 16: 175–182.Google Scholar
Nilsson A, Danielson K, Engberg G, Henneberg S. EMLA for pain relief during arterial cannulation. A double-blind, placebo-controlled study of a lidocaine-prilocaine cream. Ups J Med Sci 1990; 95: 87–94.Google Scholar
Hall AH, Kulig KW, Rumack BH. Drug- and chemical-induced methaemoglobinaemia. Clinical features and management. Med Toxicol 1986; 1: 253–260.Google Scholar
Coleman MD, Coleman NA. Drug-induced methaemoglobinaemia. Treatment issues. Drug Saf 1996; 14: 394–405.Google Scholar
Mansouri A. Methemoglobinemia. Am J Med Sci 1985; 289: 200–209.Google Scholar
Bellamy MC, Hopkins PM, Halsall PJ, Ellis FR. A study into the incidence of methaemoglobinaemia after ‘three-in-one’ block with prilocaine. Anaesthesia 1992; 47: 1084–1085.Google Scholar
Knobeloch L, Goldring J, LeMay W, Anderson H. Three cases of methemoglobinemia associated with dental anesthesia. Wis Dent Assoc J 1994; 70: 34–35.Google Scholar
Kreutz RW, Kinni ME. Life-threatening toxic methemoglobinemia induced by prilocaine. Oral Surg Oral Med Oral Pathol 1983; 56: 480–482.Google Scholar
Schott AM, Vial T, Gozzo I, Chareyre S, Delmas PD. Flutamide-induced methemoglobinemia. DICP 1991; 25: 600–601.Google Scholar
Wald-Oboussier G, Viell B. Supraklavikuläre plexusblockade mit prilocain bei patienten mit chronischer anämie. Reg Anaesth 1989; 12: 31–33.Google Scholar