Lidocaine allergy?

[milrisome]

Ok, here's a clinical question I've been thinking about, and people are asking for clinical discussions.

Called by OB. She has a pt in for induction of labor. Just starting the IOL, so doesn't want an epidural now, just wants to discuss an issue: the pt states she has a lidocaine allergy.

Go talk to pt. Not the usual crazy who says her heart rate went up with dental local. She says: I went to have my toenail worked on by podiatrist. He injected lidocaine in my toe for the procedure. After the procedure I got hives all over my body. No other meds, antibiotics, opiates, nothing else but lidocaine injection.

So: Can you have a lidocaine allergy? Is she at risk for anaphylaxis if you give her an epidural? Is there cross-reactivity between classes of local anesthetics or would it be safe to use an ester? And would you do anything for her?

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[Planktonmd]

Ok, here's a clinical question I've been thinking about, and people are asking for clinical discussions.

Called by OB. She has a pt in for induction of labor. Just starting the IOL, so doesn't want an epidural now, just wants to discuss an issue: the pt states she has a lidocaine allergy.

Go talk to pt. Not the usual crazy who says her heart rate went up with dental local. She says: I went to have my toenail worked on by podiatrist. He injected lidocaine in my toe for the procedure. After the procedure I got hives all over my body. No other meds, antibiotics, opiates, nothing else but lidocaine injection.

So: Can you have a lidocaine allergy? Is she at risk for anaphylaxis if you give her an epidural? Is there cross-reactivity between classes of local anesthetics or would it be safe to use an ester? And would you do anything for her?

As you know true Lidocaine allergy is extremely rare, and after eliminating false reactions (Vagal response, Epinephrine response, Direct intravascular injection ), the remaining cases are almost always allergic reactions to the preservative rather than the amide itself.
In the very rare occasions where it is a true allergy to Lidocaine the possibility of cross reaction with other amides is real and can not be ignored.
So knowing all this my approach in your example would be:
1- Do a skin test using preservative free Bupivacaine.
2- After 30 minutes if there is no local reaction proceed with epidural using Bupivacaine both for skin and for epidural.
3- If there is a skin reaction or you don't want to do a skin test you can do a CSE using an ester to anesthetize the skin and using only Fentanyl in the spinal and the epidural as well.

 

[huktonfonix]

I think the concern would be over possible cross reactivity between methylparaben (since we dont know and I assume the podiatrist used lido with preservative) and PABA. In this case there could be some cross reactivity although I dont know the actual numbers. Since her reaction was hives and not an anaphylactic one I think it would still be reasonable to use an ester or narcotic only in the epidural. Or maybe this would be a good time for that remi PCA I've seen mentioned a couple of times on this board. A skin test is also reasonable again since it wasnt an anaphylactic reaction.

 

[Laurel123]

I agree that a true lidocaine allergy is very rare. I think in a non-pregnant patient, I would consider using an ester for the skin as well as the epidural infusion. I believe most lidocaine reactions are from the epinephrine, and then most allergic reactions are from the preservative.

However, this brings up the point regarding drug allergies, real or fake, and pregnant patients. We have all done OB, and know that it is always in OB that crazy stuff happens. Babies for no reason at all decide to drop their heart rates and no one ever know why. I think that just the act of sitting up sometimes causes the baby to descend quickly and squeeze their heads a little and then cause decels. Anyways, my point is that when these things happen within half hour of an epidural, the first thing people say is that it is related to the epidural. Which is often BS. So my hesitation in doing any skin testing or bupivicaine is that if anything happens within that half hour after the epidural goes in, then it will be said ' well, she did say she was allergic to lidocaine and the Dr. gave a local anesthetic anyways'

 

[sspeed]

Go talk to pt. Not the usual crazy who says her heart rate went up with dental local. She says: I went to have my toenail worked on by podiatrist. He injected lidocaine in my toe for the procedure. After the procedure I got hives all over my body. No other meds, antibiotics, opiates, nothing else but lidocaine injection.

So: Can you have a lidocaine allergy? Is she at risk for anaphylaxis if you give her an epidural? Is there cross-reactivity between classes of local anesthetics or would it be safe to use an ester? And would you do anything for her?

I know this is an old post, but I'm curious as to what you found out? I had an ankle surgery on Monday and woke up to frantic doctors and nurses working around me. Along with general anesthesia I was given lidocaine on a sciatic nerve block.

During surgery, under general anesthesia, I developed a red rash all over my body, started sneezing, and my eyes swelled shut. They added benadryll to my IV and it all cleared up. I've had one other occasion where I had a mole removed, using lidocaine, and my right eye swelled up.

 

[lobelsteve]

I have seen 2 patients with true lidocaine allergy in the past 10 years.
One developed hives and swelling of the hands immediately, and soon developed some mild tightness in her throat. Epi x2, benadryl x50mg and things cooled off. It was during medial branch block. Did second diagnostic block with preservative free marcaine (thought it was the PABA) and same thing happened. Patient premedicated and went on to RF neurotomy without difficulty.

2nd patient with reported lidocaine allergy as anaphylaxis but gets dental work done. Call the dentist and he uses articaine without difficulty. I order up some and do medial branch blocks. No issues other than it comes in dental syringes and takes a needle in each end to get the med out.

 

[pd4emergence]

I know this is an old post, but I'm curious as to what you found out? I had an ankle surgery on Monday and woke up to frantic doctors and nurses working around me. Along with general anesthesia I was given lidocaine on a sciatic nerve block.

During surgery, under general anesthesia, I developed a red rash all over my body, started sneezing, and my eyes swelled shut. They added benadryll to my IV and it all cleared up. I've had one other occasion where I had a mole removed, using lidocaine, and my right eye swelled up.

I have seen one lady with a true allergist proven amide and ester local anesthetic allergy. She was having to have a general anesthetic for dental work. Appparently she was given an ester first and coded in the dentist's office, then they gave her an amide at her next procedure and she woke up again in the ICU. Talk to your primary care physician get them to send you to an allergist for skin testing.

 

[sspeed]

I just got off the phone with the allergist I went to see. Both my dermatologist and the surgery center use the same brand of lidocaine, and that brand is confrimed not to use a preservative. So that means I'm allergic to the lidocaine itself.

The dermatologist used 2-3cc's of it, the surgery center used 5cc's. 2-3cc's swelled one eye shut, 5cc's closed my throat, swelled both eyes, and gave me an entire body rash, plus I had a sneezing fit under general anesthesia.

So now I need to do testing to see what topical anesthesia I can use. I just have a sneaking feeling that the "rare" allergy to lidocaine may not be as rare as it seems to be stated. I'm surely not one of a very few people in the world with the allergy to it...

 

[TenaciousGirl]

So: Can you have a lidocaine allergy? Is she at risk for anaphylaxis if you give her an epidural? Is there cross-reactivity between classes of local anesthetics or would it be safe to use an ester? And would you do anything for her?

I know someone who is allergic to the "caine" family. I haven't looked up data on the likelihood of this but ... it is possible.

 

[Noyac]

I would not place an epidural in her.

 

[Licoricestick]

I would not place an epidural in her.

I agree - and she should be told to go and get formally tested once bub is out so the same uncertainty doesn't happen next time.

However, where I'd have a really difficult time is if there were airway concerns (more than just being pregnant) and she needs an urgent section. Spinal? AFOI (if so what do you use to topicalise)? Prop, sux, tube?

 

[SleepIsGood]

use meperidine in the spinal or epidural...has both local and opiod activity.

 

[lobelsteve]

use meperidine in the spinal or epidural...has both local and opiod activity.

I'm thinking a number of hospitals no longer stock Demerol.
I believe P n T committee's removed it from formularies after some highly publicized cases of renal patient's seizing due to active/toxic metabolites.

 

[drccw]

I'm thinking a number of hospitals no longer stock Demerol.
I believe P n T committee's removed it from formularies after some highly publicized cases of renal patient's seizing due to active/toxic metabolites.

Is that the case? Wow, that is awfully short sighted. I do believe that meperidine has some serious side effects; but it has some serious benefit as well. Are these same committee removing narcotics from forumularies because of their ability to cause apnea?

drccw

 

[IN2B8R]

Dear Colleagues, there is very good article in our Anesthesiology Journal (Nov. 2009, Vol 111, Number 5, pg 1141) that is titled Anaphylaxis and Anesthesia: Controversies and New Insights (Clinical Concepts and Commentary). Mentioned in the article are a few relevant points to the case that is posted by the OP:

1) Anaphylaxis to LA's is very uncommon and has decreased in frequency because of the decreasing use of esters (PABA is metabolite of esters that is most causative of allergic rxns).
2) Allergic rxns to amide LA's remains anecdotal.
3) Ingredients included in local anesthetic solutions such as antioxidants or preservatives including metabisulfite or parabens (also metabolized to PABA) may also elicit allergic rxns.
4) Cross reactivity among esters is common, but is absent between esters and amides.
5) LA's (without preservative or epi) maybe skin tested according to certain concentration limits (these limits are listed in the article).
6) IDTs (intradermal testing) is more sensitive but less specific than PTs (prick tests) and are more likely to trigger systemic allergic rxns and thus should be only performed after PTs.
7) The criteria of PT/IDT positivity and the different concentrations of drugs used have been strictly defined.

The OP posted an interesting, perhaps rather rare scenario, that can present itself in private practice. I have encountered this scenario once before and my patient was reportedly allergic to lidocaine (per prior testing done by an allergist). The patient received an epidural that had a preservative free ester LA and did well.

 

[Noyac]

use meperidine in the spinal or epidural...has both local and opiod activity.

This is an option but having done many meperidine spinals in my time I don't think it is strong enough for a c/s but still may be worth a try and if not strong enough then she goes to sleep. The problem is that while the last few hospitals I have worked at had meperidine they rarely had a Preservative free version.

I like your style, Sleep.

 

[Planktonmd]

Very nice post.

Thank you,

Dear Colleagues, there is very good article in our Anesthesiology Journal (Nov. 2009, Vol 111, Number 5, pg 1141) that is titled Anaphylaxis and Anesthesia: Controversies and New Insights (Clinical Concepts and Commentary). Mentioned in the article are a few relevant points to the case that is posted by the OP:

1) Anaphylaxis to LA's is very uncommon and has decreased in frequency because of the decreasing use of esters (PABA is metabolite of esters that is most causative of allergic rxns).
2) Allergic rxns to amide LA's remains anecdotal.
3) Ingredients included in local anesthetic solutions such as antioxidants or preservatives including metabisulfite or parabens (also metabolized to PABA) may also elicit allergic rxns.
4) Cross reactivity among esters is common, but is absent between esters and amides.
5) LA's (without preservative or epi) maybe skin tested according to certain concentration limits (these limits are listed in the article).
6) IDTs (intradermal testing) is more sensitive but less specific than PTs (prick tests) and are more likely to trigger systemic allergic rxns and thus should be only performed after PTs.
7) The criteria of PT/IDT positivity and the different concentrations of drugs used have been strictly defined.

The OP posted an interesting, perhaps rather rare scenario, that can present itself in private practice. I have encountered this scenario once before and my patient was reportedly allergic to lidocaine (per prior testing done by an allergist). The patient received an epidural that had a preservative free ester LA and did well.

 

[lobelsteve]

Is that the case? Wow, that is awfully short sighted. I do believe that meperidine has some serious side effects; but it has some serious benefit as well. Are these same committee removing narcotics from forumularies because of their ability to cause apnea?

drccw

A nice little article on the woe of meperidine.

http://www.paindr.com/meperidine guidelines.rtf

 

[Licoricestick]

I'm thinking a number of hospitals no longer stock Demerol.
I believe P n T committee's removed it from formularies after some highly publicized cases of renal patient's seizing due to active/toxic metabolites.

We don't have it anymore. Solves the issues of norpethidine toxicity and the drug seekers looking specifically for it.

 

[jwk]

I know someone who is allergic to the "caine" family. I haven't looked up data on the likelihood of this but ... it is possible.

You and your friend don't really know what you're talking about. When someone comes in with a "caine" allergy, it basically means nothing, since "caines" can be both amide or ester-type local anesthetics. The VAST majority of LA allergies are 1) not allergies 2) effects (usually tachcardia) of the epi often mixed in with the LA, and 3) done in a dentist's office who invariably tells the patient they're allergic to lidocaine rather than tell them the truth that it's either the epinephrine or they got an intra-vascular injection of the LA, or both.

 

[jwk]

I know this is an old post, but I'm curious as to what you found out? I had an ankle surgery on Monday and woke up to frantic doctors and nurses working around me. Along with general anesthesia I was given lidocaine on a sciatic nerve block.

During surgery, under general anesthesia, I developed a red rash all over my body, started sneezing, and my eyes swelled shut. They added benadryll to my IV and it all cleared up. I've had one other occasion where I had a mole removed, using lidocaine, and my right eye swelled up.

I just got off the phone with the allergist I went to see. Both my dermatologist and the surgery center use the same brand of lidocaine, and that brand is confrimed not to use a preservative. So that means I'm allergic to the lidocaine itself.

The dermatologist used 2-3cc's of it, the surgery center used 5cc's. 2-3cc's swelled one eye shut, 5cc's closed my throat, swelled both eyes, and gave me an entire body rash, plus I had a sneezing fit under general anesthesia.

So now I need to do testing to see what topical anesthesia I can use. I just have a sneaking feeling that the "rare" allergy to lidocaine may not be as rare as it seems to be stated. I'm surely not one of a very few people in the world with the allergy to it...

I agree you may be one of those RARE people that are allergic to lidocaine. And it is RARE, whether you understand that or not.

And sneezing under anesthesia? Not.

 

[lidocaineallerg]

Hello all. I found this thread on a google search for lidocaine and epidurals. I am not pregnant, but two weeks ago was at an ENT and had a full tonic-clonic seizure after nasal endoscopy with phenylephrine and lidocaine. The scope was already out when I had the seizure. I have zero personal or family history of epilepsy or seizures. I've had an MRI and EEG tests, both of which came out normal, and my neurologist has said that the seizure was provoked by lidocaine, and that I should avoid lidocaine in the future. Both my neurologist and the ENT echoed what is being said here, that lidocaine reaction is extremely rare (my ENT had never seen this reaction before in 30 years of practice) but in my case there seems to be no other explanation. Further, after this episode I was talking to my family and my father said that he had a dentist years ago "who insisted [he] was allergic to lidocaine", that he had collapsed and had convulsions after lidocaine was used on him during dental work. (I didn't know this before my incident or would have mentioned that to the doctors trying to diagnose the problem.)

Separately I was recently researching epidurals on a suspicion that they might involve lidocaine after reading a recent article from Amnesty International asserting that unnecessary c-sections were causing higher childbirth mortality in women in the US. My mother had two c-sections, and we have similar frames. I am trying to find out whether I should or need to pursue natural childbirth when I have children -- not anytime soon, but I don't think this information can be gotten too early.

There are many helpful answers in this thread to alternatives to lidocaine, but given my specific reaction I'm curious if any of you have thoughts on what I should do. I don't think skin testing would reveal anything in my case? And I'm concerned what an epidural with lidocaine would do if the nasal topical caused me to have a seizure.

Thanks very much for any advice.

 

[Arch Guillotti]

Closing.

This is an old thread and SDN is not the place for medical advice.