Question:
A dental patient recently had what appears to be an allergic response to
local anesthetic and I am trying to understand what happened. The patient was
a nine year old boy with no history of allergies. He received a block of the
inferior alveolar nerve with 2% lidcacaine with 1:100,000 epinephrine (a very
common local anesthetic), had a tooth restored and went home without any
apparent difficulties. The following day he returned to to office (in good
spirits) to evaluate an itchy and irregular shaped dark redish-brown area
(about 2 cm diameter) on his chin that was noticed that morning. In addition
to the red skin lesion, there were several tiny open vessicles on the same side
of the mouth, inside the lip on the mucosa. The area of the lesions (lip and
chin) were numb during his appoinment, but are far removed from the site of the
injection. This was his first reported exposure to local anesthetic and there
was no evidence of any rash or reaction on other parts of the body.
I have given the same injection probably more than a thousand times over
the years and never seen anything like this. I would have expected some
rection in the area where the anesthetic was deposited or possibly a general
rash on the arms and legs, but a reaction in this site was very unexpected. I
have recommended the family take the boy to an allergist for proper evaluation
but I would like to better understand what happened.
Answer:
You can be allergic to just about any substance. Within a couple of minutes of having my teeth cleaned with the cherry
flavored pumice stuff I started to develop symptoms similar to that of my
most severe allergy, nuts, such as yucky feeling in teeth, gums and mouth,
throat started to swell inhibiting my ability to swallow somewhat,
upset/queasy stomach. This was the first time this had ever happened to me,
although I don't recall if I ever had the cherry flavored stuff before. My
dentist looked up the ingredients on the stuff but only the active
ingredient or whatever was listed. After that he used plain pumice stuff to
clean my teeth.
So with allergies, you never know..
I suppose this could be an allergic reaction to the lidocaine, epinephrine,
or any preservatives, like parabens or sulfite.
Or could it be unrelated; some kind of irritation that happened when it
was still numb--kids do fool around.
I referred to my allergy book
'Allergies A to Z', M Lipkowitz, RP, MD, c97, Facts on File
It has a section on 'anesthetics, local'
It mentions that lidocaine is the most widely used; and epinephrine
may be the cause of adverse effects.
Here's a link on lidocaine:
http://www.cponline.gsm.com/scripts/fullmono/showmono.pl?mononum=300&...
Lidocaine by Abbott
Excerpt:
" The initial half-life of lidocaine in an otherwise healthy individual
is 7—30 minutes, followed by a terminal half-life of 1.5—2 hours.
Terminal half-lives in patients with cardiac failure, uremia, or
cirrhosis are 115 minutes, 77 minutes, and 296 minutes, respectively."
and a link on epinephrine:
http://www.cponline.gsm.com/scripts/fullmono/showmono.pl?mononum=269&...
epinephrine
So I don't know. I doubt your average allergist would have a handle on this.
Since the reaction wasn't serious, I would be inclined to forget it; but hey
I'm not a doctor; just a well informed asthmatic.
Now let me tell you my story. I had hernia surgery 2 weeks ago; in and out in
3 hours; local with MAC (the local was Bupivacaine, also got IV Versed, propofol,
and a narcotic. The evening of surgery, 12 hr later, I had a vasovagal syncope
(sudden faint), causing me to fall into my rowing machine and hit my good eye.
In reading up on the general anesthesia propofol, I see it has a half life of
12 hr in your fat; and side effects of hypotension, apnea, and shaking; I had
all of these. Had been icing my hernia til a couple of hours before the collapse.
So I have seen 2 eye doctors including a retina guy, and the original hernia
surgeon. They say I should have had a reaction sooner if it was the anesthesia.
Nobody mentioned getting tested by an allergist; even tho I had a very
serious reaction (when I came to, I was having trouble breathing; then was
shaking all over for an hour) Called my surgeon at 11:30pm and decided I was
stressed out and should go to bed. [Surgeon's theory is vasovagal syncope
cause by surgery trauma, but I felt great all day after surgery, it was an
uncomplicated direct inguinal hernia] I had these same 4 drugs for a hernia
on the other side 4 yr. ago with no problems.
The eye seems to be OK, just a bunch of floaters and flashes due to
detached vitreous jelly--I have to take it easy for a few weeks.
And you'r worried about a brown spot on a kid's face 24 hr later.
But you'r right to be concerned, and suggesting seeing an allergist
should be a safe thing to do.
Funny this should come up now. I have just gone through wisdom teeth being
extracted this past week, but because of my extreme allergic history was
tested b my allergist for the locals that were available to my Oral
Surgeon.
Carbocain 3% was extremely reactive, on the scratch test alone, within
seconds. A secondary testing was not done on this, but was on the
remaining ones with under the upper layer of skin injections (Marcaine
0.5%, Lidocaine HCL 2% both with Epinephrine 1:200,00 and saline control
and histamine control). These were negative.
I was given 16MG of Medrol OD (one each day - for 2 days prior to the
surgery) and 50MG of Benadryl PO to be taken 2 hrs prior to the extraction
procedure as a precautionary measure. because I am highly allergic to all
antibiotics, sulfas, mycins and penicillins I was not given anything to
take after the procedure... All went well and no infection has resulted. I
was kept at the office for 2 hours after the procedure, under monitoring
before being released into my family's care.
It is always wise to test for possible reactions (I had never had to
undergo any procedures before so they had no idea if/how I would react).
This is especially true of low body weight patients. I may be 45 years
old, but only 5'1" and 92 lbs. My doctors are very careful to regulate
all medications accordingly.
Reactions to medications as well as anesthesias are not uncommon and should
be treated with extreme caution and monitoring at all times.
