Published online April 3, 2006
PEDIATRICS Vol. 117 No. 4 April 2006, pp. e806-e809 (doi:10.1542/10.1542/peds.2005-1952)
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EXPERIENCE & REASON

Severe Methemoglobinemia Complicating Topical Benzocaine Use During Endoscopy in a Toddler: A Case Report and Review of the Literature

Ahmed Dahshan, MD, FAAP and G. Kevin Donovan, MD, FAAP

Division of Pediatric Gastroenterology, Department of Pediatrics, Oklahoma University Health Sciences Center, Tulsa, Oklahoma

ABSTRACT

Severe methemoglobinemia resulting from the use of topical benzocaine has been reported in adults as a rare complication. Here we report a case of severe acquired methemoglobinemia resulting from topical use of benzocaine spray during diagnostic upper gastrointestinal endoscopy in a 3-year-old boy with repeated episodes of hematemesis 3 weeks posttonsillectomy. He developed marked cyanosis and became increasingly agitated immediately after completion of his unremarkable endoscopic procedure, which was performed under intravenous sedation. He did not respond to maximum supplemental oxygen and had increased respiratory effort. His pulse oximetry dropped to 85%, but simultaneous arterial blood-gas analysis showed marked hypoxemia (PO2 = 29%) and severe methemoglobinemia (methemoglobin = 39%). His cyanosis and altered mental status promptly resolved after intravenous administration of methylene blue. In patients with methemoglobinemia, pulse oximetry tends to overestimate the actual oxygen saturation and is not entirely reliable. Posttonsillectomy bleeding is a rare but occasionally serious complication that could occur weeks after the surgery, although it more commonly occurs within the first few days. Physicians should remain aware of the possibility of its late onset. This case illustrates the severity of acquired methemoglobinemia that may result from even small doses of topical benzocaine and highlights the fact that prompt treatment of the disorder can be life saving. We question the rationale for routine use of topical anesthetic spray for sedated upper gastrointestinal endoscopy in children. By bringing the attention of pediatricians to this rare but serious complication, we hope that it will result in its improved recognition and possible prevention.

Key Words: methemoglobinemia • endoscopy • benzocaine • tonsillectomy

Abbreviations: GI, gastrointestinal • ABG, arterial blood gas • SaO2, arterial oxygen saturation

Accepted Sep 29, 2005.


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