A DOCS Education member seeks the faculty’s assistance:
I am an endodontist who has received a referral for a 31-year-old caucasian male with a history of methemoglobinemia in response to esophageal benzocaine spray. The patient needs two root canals on vital teeth #4 and #19 and seven fillings.
After reviewing the literature with my local anesthesiologist's help, bupivacaine seems to be the medication with the least amount of risk. The recommendation from the anesthesiologist is not to perform sedation in the office, other than possibly nitrous as well as having an IV ready for up to 50 mgs TOP DOSE of methylene blue 1.0 -2.0 mg/kg IV every 60 minutes and very small amounts of bupivacaine per session. The other option would be general anesthesia.
What are your thoughts?
Dr. Leslie Fang, DOCS Education faculty, responds:
Methemoglobinemia is a rare disease and this patient is clearly at risk due to his problems dealing with benzocaine. With respect to the local anesthetics, articaine and prilocaine should be avoided. I agree that bupivacaine is a safer local anesthetic to use judiciously.
In patients with methemoglobinemia, treatment consists of high flow oxygen and the use of methylene blue at 1-2 mg/kg IV push over five minutes followed by normal saline flush. I would advise you to avoid the use of trimethoprim and sulfonamide. There are no contraindications with the use of nitrous.
The information contained in this, or any case study post in Incisor should never be considered a proper replacement for necessary training and/or education regarding adult oral conscious sedation. Regulations regarding sedation vary by state. This is an educational and informational piece. DOCS Education accepts no liability whatsoever for any damages resulting from any direct or indirect recipient's use of or failure to use any of the information contained herein. DOCS Education would be happy to answer any questions or concerns mailed to us at 106 Lenora Street, Seattle, WA 98121. Please print a copy of this posting and include it with your question or request.
