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SPA Newsletter.
EMLA Toxicity After Application for Allergy Skin TestingParker JF, Vats A, Bauer G. Pediatrics 2004;113:410-411Reviewed by: Thomas J. Mancuso, MD, FAAP EMLA is now widely used to provide topical analgesia to a depth of 5mm. Adverse effects that have been reported have generally mild, local reactions. Methemoglobionemia and seizures have been reported following higher than recommended doses. This report describes a case in which seizures occurred despite administration of a proper dose of EMLA, but spread over a larger than recommended surface area. The child involved was a healthy 3-year-old scheduled for allergy skin testing. Her parents were given a 5 gm tune of EMLA to be applied to the child's back and covered. The parents applied the EMLA to the area of her back as directed (approximately 1140cm2) and approximately 1 hour later, while driving to the allergists office, the parents noted their child was less responsive then shortly thereafter she was foaming at her mouth, shaking all extremities, eyes open and was unresponsive. While waiting for an ambulance, the father noted a raised erythematous rash on the child's back and removed the plastic wrap and small amount of cream remaining on her back. Emergency services reported that she had peripheral and perioral cyanosis. Supplemental oxygen was given en route to the hospital. In the ED she was alert and interactive, but later developed moderate hypotension and her cyanosis worsened. Venous blood gases approximately five hours after EMLA application: pH 7.37, PvCO2 42, PvO2 90 HCO3 24 oxyhemoglobin 80%, methemoglobin 17.7%. Lidocaine level (2.5 hr after EMLA application) 3.0 micrograms/ml. She spent an uneventful night in the hospital receiving supplemental oxygen. The following morning her methemoglobin level was 1.4% The authors speculate that the seizure was due to both an elevated lidocaine and methemoglobin levels. These may have resulted from EMLA application to a large area of eczematous skin. Commentary It always something!
This special section in a recent issue of Science describes the problems with advances in the field as well as advances made in analysis, planning and synthesis of new medications. There are several articles in the section. The piece begins with a lament that, despite increases in R&D, the number of new agents has remained steady, perhaps a result of companies falling prey to "the blockbuster syndrome". Following are articles about new developments in synthesis including protein kinase inhibitors. Although most work with protein-kinase inhibitors focuses on uses as anti-neoplastic agents, these agents may have roles as anti-inflammatory medications. The essay on novel drug delivery systems does not describe any specific uses in anesthesia but, given the many ways in which anesthesiologists currently administer medications, it is worth a look. Table of Contents
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