Lidocaine allergy in LAboring patient.

[Laurel123]

So I have this healthy term patient come in with her first baby and wants an epidural. However, all over her chart it is written that she is allergic to lidocaine. She says she is allergic to lidocaine. The front of the chart says lidocaine allergy in big red letters.

Anyhow, when asked to describe her allergy, she says that when she was getting a mole off her scalp at the derms office, they injected lidocaine and she gets light-headed, dizzy, pounding heart, breathing fast, and some tongue numbness. It subsides and the derm sends her home with some benadryl (what?). She refuses novacaine at the dentists. She had a laparoscopy done in the past (no records available) without any issues.

My clinical judgement is that she felt the epinephrine in the lidocaine, which I am sure they used for the scalp lesion. However, she is nine months pregnant and there is no documentation of her ever getting local anesthetic without an issue and her chart says lidocaine allergy. So I can't bring myself to do an epidural even though I am fairly certain that she doesn't really have a lidocaine allergy. But if anything happens, and anything can happen in OB, I would be the first person they would point the finger at. So she got an intrathecal shot of clonidine and fentanyl (without local at skin!) which at 8 cm on pitocin did nothing for her.

Had she not been pregnant, I would have done local.
So, would you have done the epidural with local?

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[jetproppilot]

So I have this healthy term patient come in with her first baby and wants an epidural. However, all over her chart it is written that she is allergic to lidocaine. She says she is allergic to lidocaine. The front of the chart says lidocaine allergy in big red letters.

Anyhow, when asked to describe her allergy, she says that when she was getting a mole off her scalp at the derms office, they injected lidocaine and she gets light-headed, dizzy, pounding heart, breathing fast, and some tongue numbness. It subsides and the derm sends her home with some benadryl (what?). She refuses novacaine at the dentists. She had a laparoscopy done in the past (no records available) without any issues.

My clinical judgement is that she felt the epinephrine in the lidocaine, which I am sure they used for the scalp lesion. However, she is nine months pregnant and there is no documentation of her ever getting local anesthetic without an issue and her chart says lidocaine allergy. So I can't bring myself to do an epidural even though I am fairly certain that she doesn't really have a lidocaine allergy. But if anything happens, and anything can happen in OB, I would be the first person they would point the finger at. So she got an intrathecal shot of clonidine and fentanyl (without local at skin!) which at 8 cm on pitocin did nothing for her.

Had she not been pregnant, I would have done local.
So, would you have done the epidural with local?

Yes.

I agree with your clinical judgement.

If you're worried about legal issues, use something other than lidocaine, which you don't use for a labor epidural anyway.

 

[militarymd]

After informed consent, I would have given her an epidural if she wanted one.

 

[rmh149]

I would have given her the epidural after explaining to her exactly what you just told us. She probably would have said...."please proceed". I agree with you...it probably was the Epi in the lidocaine and not a true drug allergy.

Just today I had a parturient for repeat CS that stated she was allergic to morphine. It was all over the chart, her wrist band, and the computer. However, she states that morphine makes her "itch". I told her that was a normal histamine response and I could write for meds to attenuate the "itch". She agreed to duromorph with her spinal for the benefit of pain control over the PCA. All is good. Patient is happy.

question, why not use something else for the local other than lidocaine....like naropin or marcaine?

 

[Laurel123]

True, true. And I considered using bupivicaine/ropivicaine or something only. Plus, I really didn't think it was a lidocaine allergy. However, my only issue was that there wasn't any record or what really happened at the derm's office, only the patient's recollection. And when she first relayed the information to the nurse, she said 'shortness of breath' with lidocaine, which was in the chart. And if it really were a true allergy, she would probabably be allergic to all the amides. And when I tried to use informed consent, she asked me what I thought. ugh, litiginous medical environment sucks.

Anyways, like I said, if she hadn't been pregnant, I absolutely would have given her bupivicaine. But these darn pregnant women, they turn on the wrong side and their blood pressure drops and the baby gets pissed.... and everyone always likes to point the finger at the epidural.

 

[rmh149]

True, true. And I considered using bupivicaine/ropivicaine or something only. Plus, I really didn't think it was a lidocaine allergy. However, my only issue was that there wasn't any record or what really happened at the derm's office, only the patient's recollection. And when she first relayed the information to the nurse, she said 'shortness of breath' with lidocaine, which was in the chart. And if it really were a true allergy, she would probabably be allergic to all the amides. And when I tried to use informed consent, she asked me what I thought. ugh, litiginous medical environment sucks.

Anyways, like I said, if she hadn't been pregnant, I absolutely would have given her bupivicaine. But these darn pregnant women, they turn on the wrong side and their blood pressure drops and the baby gets pissed.... and everyone always likes to point the finger at the epidural.

That paints a little different picture. "shortness of breath" scares me too. That probably would have pushed me over the edge too.

 

[Planktonmd]

True, true. And I considered using bupivicaine/ropivicaine or something only. Plus, I really didn't think it was a lidocaine allergy. However, my only issue was that there wasn't any record or what really happened at the derm's office, only the patient's recollection. And when she first relayed the information to the nurse, she said 'shortness of breath' with lidocaine, which was in the chart. And if it really were a true allergy, she would probabably be allergic to all the amides. And when I tried to use informed consent, she asked me what I thought. ugh, litiginous medical environment sucks.

Anyways, like I said, if she hadn't been pregnant, I absolutely would have given her bupivicaine. But these darn pregnant women, they turn on the wrong side and their blood pressure drops and the baby gets pissed.... and everyone always likes to point the finger at the epidural.

True allergy to Lidocaine is extremely rare and it does not necessarily mean allergy to all Amides.
If you are really concerned you can always do a simple skin test with Bupivacaine before using it, If no reaction in 30 minutes you can proceed knowing at least there will be no IGE mediated reaction.

 

[IN2B8R]

I was in a similar scenario as a resident. I ended up using an ester LA: 2-chloroprocaine as an infusion. Worked without any problems. Other alternatives for you would have been: demerol, which acts both as a narcotic and as a local anesthetic. Plain narcotics, which would be effective for visceral pain only (not the somatic pain of stage 2 of labor), would also work. All in all, the likelyhood that anyone has an amide allergy is extremely small. Skin testing is always a recommendation that I make to my patients when they present with such history--as an oupatient, since I have no time for this in my practice.

 

[jwk]

True allergy to Lidocaine is extremely rare and it does not necessarily mean allergy to all Amides.
If you are really concerned you can always do a simple skin test with Bupivacaine before using it, If no reaction in 30 minutes you can proceed knowing at least there will be no IGE mediated reaction.

Extremely rare - as in no documented cases of true lidocaine allergy.

 

[rmh149]

True allergy to Lidocaine is extremely rare and it does not necessarily mean allergy to all Amides.
If you are really concerned you can always do a simple skin test with Bupivacaine before using it, If no reaction in 30 minutes you can proceed knowing at least there will be no IGE mediated reaction.

Good idea....

 

[TIVA]

It's probably not lidocaine that she's allergic too. I agree that her reaction was probably due to epi originally, or she had an intravascular injection because her symptoms are consistent with somebody can LA intravascularly.

More probable is that she is allergic to the preservative in lidocaine -- methyl paraben. In such a situation, if you use preservative free lidocaine (i.e. cardiac lidocaine), you should have no issues.

 

[urgewrx]

Labor epidural is an elective procedure. No epidural for her. IV PCA would be my tx. She should get skin tested. Delivering a baby is probably the most important event in a woman's life. Why take chances of ruining it?

 

[sdn1977]

Extremely rare - as in no documented cases of true lidocaine allergy.

I'd agree, extremely rare...but there have been a few documented allergic reactions (ok - well, two...) One was a contact dermatitis in a plant worker and another was a published case of an immune mediated allergy to lidocaine. However, less than 1% of local anesthetic allergies are immune related & allergists suspect that amides are a very much smaller percentage of this total.

Interestingly, altho some of the more obvious causes of a physiologic reaction to a local anesthetic - in this case in a derm's office or more frequently, by dentists are the epi component injected into an extremely vascular area of the oral mucosa or the head or neck, vasovagal effect of the injection itself, preservative, etc....other rarer reasons can be the cause.

For the amides, there is a C1 esterase inhibitor deficiency which can be hereditary or acquired & again, altho rare, can be a cause of reactions to amides. This is not an allergy - just an abnormality in how the amide is metabolized. You might see an exagerated response to the anesthetic. You wouldn't know this pt unless he/she had been tested after a reaction by an allergist or had a family member in a similar situation.

Also, the local anesthetics are molecules which are too small to be antigens themselves, but they are sufficiently abnormal in the body they bind to haptens which, depending on the hapten, can be a cause of an immune response. If the hapten is sufficiently antigenic, it can cause an IgE mediated Type I response with release of all that "stuff" - histamine, serotonin, leukotrienes, etc....but, more often they are of the non-IgE mediated responses (Type IV) which cause a release of bioamines, including histamine - thus the infrequent dermatitis, but the possibility (altho I agree - extremely rare) of something greater. Unfortunately, you can't predict which hapten the anesthetic will bind to. The Type IV's are slower to develop (4-14 days) so you might not even see it yourself.

There is one case in the literature of a primigravida who self reported an allergy to lidocaine & chlorprocaine (I think). She was admitted at 38 weeks for skin testing with bupivacaine & reacted negatively. Sent home. At term, she was admitted, requested an epidural & bupivacaine was used without reaction. Later was skin tested for lidocaine & was negative. That's a whole lotta work for a first pregnancy - she may have been the researcher or married to one??

I certainly can't tell you what to do medically, but thought the drug info might be interesting. Unfortunately, patients get told they've had a reaction to the local anesthetic & they think its an allergy...when it was just a reaction. They don't get the difference in physiologic terms. (Apologies for the length..)

 

[Planktonmd]

I'd agree, extremely rare...but there have been a few documented allergic reactions (ok - well, two...) One was a contact dermatitis in a plant worker and another was a published case of an immune mediated allergy to lidocaine. However, less than 1% of local anesthetic allergies are immune related & allergists suspect that amides are a very much smaller percentage of this total.

Interestingly, altho some of the more obvious causes of a physiologic reaction to a local anesthetic - in this case in a derm's office or more frequently, by dentists are the epi component injected into an extremely vascular area of the oral mucosa or the head or neck, vasovagal effect of the injection itself, preservative, etc....other rarer reasons can be the cause.

For the amides, there is a C1 esterase inhibitor deficiency which can be hereditary or acquired & again, altho rare, can be a cause of reactions to amides. This is not an allergy - just an abnormality in how the amide is metabolized. You might see an exagerated response to the anesthetic. You wouldn't know this pt unless he/she had been tested after a reaction by an allergist or had a family member in a similar situation.

Also, the local anesthetics are molecules which are too small to be antigens themselves, but they are sufficiently abnormal in the body they bind to haptens which, depending on the hapten, can be a cause of an immune response. If the hapten is sufficiently antigenic, it can cause an IgE mediated Type I response with release of all that "stuff" - histamine, serotonin, leukotrienes, etc....but, more often they are of the non-IgE mediated responses (Type IV) which cause a release of bioamines, including histamine - thus the infrequent dermatitis, but the possibility (altho I agree - extremely rare) of something greater. Unfortunately, you can't predict which hapten the anesthetic will bind to. The Type IV's are slower to develop (4-14 days) so you might not even see it yourself.

There is one case in the literature of a primigravida who self reported an allergy to lidocaine & chlorprocaine (I think). She was admitted at 38 weeks for skin testing with bupivacaine & reacted negatively. Sent home. At term, she was admitted, requested an epidural & bupivacaine was used without reaction. Later was skin tested for lidocaine & was negative. That's a whole lotta work for a first pregnancy - she may have been the researcher or married to one??

I certainly can't tell you what to do medically, but thought the drug info might be interesting. Unfortunately, patients get told they've had a reaction to the local anesthetic & they think its an allergy...when it was just a reaction. They don't get the difference in physiologic terms. (Apologies for the length..)

Nice response.
And because you need certain haptens to trigger an IGE mediated reaction to amides, you could argue that even a true allergy to an amide local anesthetic could be inconsistent, which means even If you had the extremely rare reaction in the past you might not have it again.

 

[sdn1977]

Nice response.
And because you need certain haptens to trigger an IGE mediated reaction to amides, you could argue that even a true allergy to an amide local anesthetic could be inconsistent, which means even If you had the extremely rare reaction in the past you might not have it again.

Again...very true which leaves you in a bit of a conundrum when predicting....

 

[rmh149]

Just want to step outside the box here. What if she wasnt allergic to Lidocaine at all...or a response to epinepherine? What if she never received lidocaine by the dermatologist? What if her reaction with her previous procedure was a sub-toxic side effect to Marcaine?

I say this because when our GYN patients receive a pudendal block, (highly vascular) with marcaine they frequently complain of the feeling of tongue swelling/numbing, shortness of breath, facial twitch....all around strange feeling. It was frequent enough to switch to another LA.

Is it possible she received an inadverdent intravenous injection of bupivicaine by the dermatologist?

Is the patient absolutely sure she received lidocaine...or is was it just an assumption?

thoughts.....

 

[sdn1977]

Just want to step outside the box here. What if she wasnt allergic to Lidocaine at all...or a response to epinepherine? What if she never received lidocaine by the dermatologist? What if her reaction with her previous procedure was a sub-toxic side effect to Marcaine?

I say this because when our GYN patients receive a pudendal block, (highly vascular) with marcaine they frequently complain of the feeling of tongue swelling/numbing, shortness of breath, facial twitch....all around strange feeling. It was frequent enough to switch to another LA.

Is it possible she received an inadverdent intravenous injection of bupivicaine by the dermatologist?

Is the patient absolutely sure she received lidocaine...or is was it just an assumption?

thoughts.....

In a round about way...that is the point of my post. You probably don't know - in fact many pts over 55-60 still think their dentist uses novocaine.

But....I'm not know sure knowing will change the decision made because there are so many reasons for the reaction, whether is was lidocaine or not. You still have to make the choice based on the information available, whether its reliable or not.

 

[Laurel123]

Just want to step outside the box here. What if she wasnt allergic to Lidocaine at all...or a response to epinepherine? What if she never received lidocaine by the dermatologist? What if her reaction with her previous procedure was a sub-toxic side effect to Marcaine?

I say this because when our GYN patients receive a pudendal block, (highly vascular) with marcaine they frequently complain of the feeling of tongue swelling/numbing, shortness of breath, facial twitch....all around strange feeling. It was frequent enough to switch to another LA.

Is it possible she received an inadverdent intravenous injection of bupivicaine by the dermatologist?

Is the patient absolutely sure she received lidocaine...or is was it just an assumption?

thoughts.....

It's all possible. The unfortunate thing was there was no documentation about this reaction and the procedure. There was just the story from the patient and the current chart with 'ALL: LIDOCAINE' stamped all over it. I could just see the lawyers 'but doctor, it says on her chart that she is allergic to lidocaine'....