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Allergy to Local Anesthetics is a Rarity: Review of Diagnostics and Strategies for Clinical Management. Clin Rev Allergy Immunol 2023; 64:193-205. [PMID: 35482282 DOI: 10.1007/s12016-022-08937-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2022] [Indexed: 11/03/2022]
Abstract
Local anesthetics (LA) are commonly used in procedures and in topical agents for pain management. With the increasing use of LA drugs, the management of LA reactions is more frequently encountered in the office and in operating rooms. True allergic reactions involving IgE-mediated reactions and anaphylaxis are rare; they have only been identified in case reports and account for less than 1% of adverse LA reactions. Most reactions are non-allergic or are a result of hypersensitivity to other culprits such as preservatives, excipients, or other exposures. LA reactions that are misclassified as true allergies can lead to unnecessary avoidance of LA drugs or delays in surgical procedures that require their use. A detailed history of prior LA reactions is the first and most crucial step for understanding the nature of the reaction. Reactions that are suspicious for an immediate hypersensitivity reaction can be evaluated with skin prick and intradermal testing with subsequent graded challenge. Reactions that are suspicious for a delayed hypersensitivity reaction can be evaluated with patch testing.
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2
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Kvisselgaard AD, Melchiors BB, Krøigaard M, Garvey LH. Lidocaine as a Rare and Hidden Allergen in the Perioperative Setting: A Case Report. A A Pract 2019; 12:430-432. [PMID: 30633002 DOI: 10.1213/xaa.0000000000000955] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Local anesthetics are used throughout the health care system. In the perioperative setting and in other settings of exposure to local anesthetics, true allergy is reported very rarely. We present an unusual case of immediate-type perioperative hypersensitivity to lidocaine with cross-reaction to mepivacaine, which was missed on initial investigation. This case illustrates that lidocaine may be a "hidden allergen" in the perioperative setting and should always be considered a potential culprit in cases of suspected perioperative hypersensitivity. The case also demonstrates that suspected perioperative hypersensitivity requires highly specialized investigation and close collaboration between allergists and anesthesiologists.
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Affiliation(s)
- Ask D Kvisselgaard
- From the Danish Anaesthesia Allergy Centre, Allergy Clinic, Department of Dermatology and Allergology, Herlev and Gentofte Hospital, University of Copenhagen, Denmark
| | - Birgitte B Melchiors
- From the Danish Anaesthesia Allergy Centre, Allergy Clinic, Department of Dermatology and Allergology, Herlev and Gentofte Hospital, University of Copenhagen, Denmark.,Department of Neuroanaesthesia, Rigshospitalet, University of Copenhagen, Denmark
| | - Mogens Krøigaard
- From the Danish Anaesthesia Allergy Centre, Allergy Clinic, Department of Dermatology and Allergology, Herlev and Gentofte Hospital, University of Copenhagen, Denmark
| | - Lene H Garvey
- From the Danish Anaesthesia Allergy Centre, Allergy Clinic, Department of Dermatology and Allergology, Herlev and Gentofte Hospital, University of Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Kang C, Lee GS, Kim SB, Won YG, Lee JK, Jung YS, Cho HJ. Comparison of postoperative pain control methods after bony surgery in the foot and ankle. Foot Ankle Surg 2018; 24:521-524. [PMID: 29409271 DOI: 10.1016/j.fas.2017.06.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 06/14/2017] [Accepted: 06/16/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND We performed a prospective study to evaluate and compare the effectiveness of postoperative pain control methods after bone surgery in the foot and ankle. METHODS Among the patients who underwent foot and ankle surgery from June 2014 to September 2015 with an ultrasound-guided nerve block, 84 patients who fully completed a postoperative pain survey were enrolled. An opioid patch (fentanyl patch, 25mg) was applied in group A (30 patients). Diluted anesthetic (0.2% ropivacaine, 30ml) was injected into the sciatic nerve once, about 12h after the preoperative nerve block, in group B (27 patients). Periodic intramuscular injection of an analgesic (ketorolac [Tarasyn], 30mg) was performed in group C (27 patients). The visual analogue scale (VAS) pain scores at 6, 12, 18, 24, and 48h after surgery were checked, and the complications of all methods were monitored. RESULTS The mean VAS pain score was lower in group B, with a statistically significant difference (P<.05) between groups A, B, and C at 12 and 18h after surgery. Four patients in group A experienced nausea and vomiting; however, no other patients complained of any complications or adverse effects. CONCLUSION The ultrasound-guided injection of a diluted anesthetic into the sciatic nerve seemed to be the most useful method for controlling pain in the acute phase after bone surgery in the foot and ankle. The injection of the diluted anesthetic once on the evening of the day of surgery resulted in less postoperative pain in the patients. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Chan Kang
- Department of Orthopaedic Surgery, Chungnam National University School of Medicine, Republic of Korea
| | - Gi-Soo Lee
- Department of Orthopedic Surgery, Konyang University College of Medicine, Daejeon, Republic of Korea; Konyang University Myunggok Medical Research Institute, Daejeon, Republic of Korea.
| | - Sang-Bum Kim
- Department of Orthopedic Surgery, Konyang University College of Medicine, Daejeon, Republic of Korea
| | - You-Gun Won
- Department of Orthopedic Surgery, Konyang University College of Medicine, Daejeon, Republic of Korea
| | - Jeong-Kil Lee
- Department of Orthopaedic Surgery, Chungnam National University School of Medicine, Republic of Korea
| | - You-Sun Jung
- Department of Orthopedic Surgery, Konyang University College of Medicine, Daejeon, Republic of Korea
| | - Hyung-June Cho
- Department of Orthopedic Surgery, Konyang University College of Medicine, Daejeon, Republic of Korea
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Trautmann A, Goebeler M, Stoevesandt J. Twenty Years' Experience with Anaphylaxis-Like Reactions to Local Anesthetics: Genuine Allergy is Rare. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:2051-2058.e1. [PMID: 29655774 DOI: 10.1016/j.jaip.2018.04.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 03/25/2018] [Accepted: 04/02/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Anaphylaxis-like reactions occur within minutes after the application of local anesthetics (LA), most commonly during dental interventions. Impressive symptoms including respiratory distress or loss of consciousness frequently give rise to a suspicion of allergy and may prompt patients and treating physicians to refuse future LA injections. OBJECTIVE Nonallergic mechanisms are responsible for the majority of LA-induced immediate-type reactions. In view of the preponderance of nonallergic reactions, the question arises whether genuine LA allergy may be missed during routine testing procedures. METHODS We retrospectively evaluated clinical data and test results from patients referred to our allergy clinic within the past 20 years for diagnostic workup of LA-induced immediate-type reactions. RESULTS Of 402 evaluated patients, 29 had an episode of acute urticaria within 30 minutes after LA injections, and the remaining 373 had a history of mainly subjective cutaneous, respiratory, cardiovascular, and neurological complaints. Of the patients reporting urticaria with or without angioedema, 14 were diagnosed with a spontaneous episode of urticaria, 13 had allergic or nonallergic reactions to other agents, and 2 had IgE-mediated LA allergy. LA allergy was definitely excluded by 771 subcutaneous provocation tests with skin test negative LA, thereby demonstrating the high predictive value of negative intradermal testing. CONCLUSIONS Skin testing and provocative LA challenge are useful to exclude LA allergy, and this testing procedure seems to be appropriate to identify the extremely rare cases with IgE-mediated LA allergy.
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Affiliation(s)
- Axel Trautmann
- Department of Dermatology, Venereology and Allergy, University Hospital Würzburg, Würzburg, Germany.
| | - Matthias Goebeler
- Department of Dermatology, Venereology and Allergy, University Hospital Würzburg, Würzburg, Germany
| | - Johanna Stoevesandt
- Department of Dermatology, Venereology and Allergy, University Hospital Würzburg, Würzburg, Germany
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Kvisselgaard AD, Mosbech HF, Fransson S, Garvey LH. Risk of Immediate-Type Allergy to Local Anesthetics Is Overestimated-Results from 5 Years of Provocation Testing in a Danish Allergy Clinic. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 6:1217-1223. [PMID: 28988784 DOI: 10.1016/j.jaip.2017.08.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 07/14/2017] [Accepted: 08/15/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Local anesthetics (LAs) are used in many health care settings and exposure during a lifetime is almost inevitable. Immediate-type allergy to LAs is considered rare among allergy experts but is commonly suspected by health care workers from other specialties, and by patients. OBJECTIVE The main aim of this study was to investigate the incidence of immediate-type allergy to LAs in our regional allergy clinic over the 5-year period 2010 to 2014. METHODS This was a retrospective single-center study of patients referred to a regional allergy clinic (excluding patients with perioperative reactions) with suspected immediate allergy to LAs, who had undergone subcutaneous provocation with 1 or more LAs. Patients were identified in the hospital clinical coding system and clinical information about the reaction and investigation results was obtained from their medical records. RESULTS A total of 164 patients (123 women/41 men; median age, 56 years; range, 7-89 years) who had 189 provocations with LAs were included over the 5-year period 2010 to 2014. All 164 patients had negative subcutaneous provocations to all 189 tests with LAs (95% CI, 0%-1.83%). Another allergen was identified in 10% (n = 17) of the patients. CONCLUSIONS None of the 164 patients with suspected immediate-type allergy to LAs reacted on provocation. Thus, no patients have been diagnosed with an immediate allergy to LAs in our regional allergy clinic in the 5-year period studied, and allergy to LAs must be considered very rare. Alternative mechanisms should be considered, but if symptoms are consistent with allergy, other potential allergens should be investigated.
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Affiliation(s)
- Ask D Kvisselgaard
- Allergy Clinic, Department of Dermatology and Allergology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark.
| | - Holger F Mosbech
- Allergy Clinic, Department of Dermatology and Allergology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Sara Fransson
- Allergy Clinic, Department of Dermatology and Allergology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Lene H Garvey
- Allergy Clinic, Department of Dermatology and Allergology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
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Abstract
BACKGROUND Local anesthetic (LA) allergy is a concern for dermatologic surgeons given the large number of procedures performed yearly with LAs. Many patients also have anxiety about past or potential anesthesia allergy. OBJECTIVE This article will review the symptoms of IgE-mediated allergic reactions, the prevalence of IgE-mediated LA allergy, discuss common mimics of LA, and propose a practical approach for diagnostic and therapeutic options for LA allergy for the dermatologic surgeon in practice. MATERIALS AND METHODS A literature search of Pubmed using keywords "lidocaine," "local anesthetic," "hypersensitivity," and "allergy" was performed. RESULTS Amide anesthetics result in the most reports of true local anesthetic immediate hypersensitivity. CONCLUSION True IgE-mediated anaphylaxis to local anesthesia is very rare. Dermatologic surgeons should be aware of the symptoms of anesthetic allergy and its mimickers, as well as how to manage allergic reactions in their clinical practice.
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A case of severe NSAID exacerbated respiratory disease (NERD) following a dental procedure in a child. Eur Arch Paediatr Dent 2016; 17:277-81. [PMID: 27179970 DOI: 10.1007/s40368-016-0233-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 04/15/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND An allergic reaction following a dental procedure is a rare event. A local anaesthetic (LA) may initially be suspected as a causative agent but allergy to dental LA solutions is extremely rare. CASE REPORT This report concerns a 13 year old child who underwent dental treatment and was exposed to Lignospan Special(®) LA, mouthwash, latex gloves, ibuprofen medication, and a Magnum(®) (almond) ice cream all within 45 min. He subsequently developed acute symptoms of nasal rhinorrhoea, facial flushing, peri-orbital and lip angioedema, followed by throat tightness and wheeze (respiratory compromise). His acute reaction was treated by his medical practitioner with oral anti-histamines, steroid and nebulised salbutamol. The child was referred to a local allergist. The child underwent detailed allergic investigations including skin prick tests, blood tests, incremental local anaesthetic challenge and ibuprofen challenge. The patient was diagnosed with NSAID exacerbated respiratory disease (NERD), a hypersensitivity reaction to ibuprofen. FOLLOW-UP The patient was advised to avoid NSAIDs and to wear a medic-alert (allergy) bracelet. A detailed written report was sent to the patient's dentist and GP. CONCLUSIONS In the context of a suspected reaction post dental procedure, local anaesthetic should be considered a possible allergen but other important considerations include analgesics, antibiotics, and latex. All genuine allergic reactions need to be investigated. This report highlights NERD as a possible adverse outcome following dental treatment.
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Barbarroja-Escudero J, Sanchez-Gonzalez MJ, Rodriguez-Rodriguez M, Antolin-Amerigo D, Vélez D, Medina-Exposito I, Sanchez-Gomez-Aparici E, Piteiro AB, Alvarez-Mon M. Fixed drug urticaria: a report of two patients. Allergol Int 2015; 64:101-3. [PMID: 25572565 DOI: 10.1016/j.alit.2014.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2014] [Revised: 07/17/2014] [Accepted: 07/26/2014] [Indexed: 10/24/2022] Open
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Calderon AL, Diot N, Benatir F, Christin F, Hautin E, Truc C, Allaouchiche B, Boselli E. Immediate allergic cross-reactivity to levobupivacaine and ropivacaine. Anaesthesia 2012; 68:203-5. [PMID: 23121555 DOI: 10.1111/j.1365-2044.2012.07314.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Allergic reactions to amide local anaesthetic agents are rare. We report the case of a 74-year-old man who suffered anaphylaxis, presenting with cardiovascular collapse, immediately after receiving regional anaesthesia on two separate occasions, the first involving the use of levobupivacaine and the second using ropivacaine. Skin testing revealed positive reactions to both levobupivacaine and ropivacaine, and negative reactions to articaine and lidocaine. Severe allergic reactions can be caused by the amide local anaesthetic drugs, levobupivacaine and ropivacaine.
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Affiliation(s)
- A L Calderon
- Department of Anaesthesiology and Intensive Care, Édouard Herriot Hospital, HCL, Lyon, France
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Bhole MV, Manson AL, Seneviratne SL, Misbah SA. IgE-mediated allergy to local anaesthetics: separating fact from perception: a UK perspective. Br J Anaesth 2012; 108:903-11. [PMID: 22593127 DOI: 10.1093/bja/aes162] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Local anaesthetic (LA) agents have been routinely used in dentistry, ophthalmology, minor surgery, and obstetrics since the late nineteenth century. Reports relating to adverse reactions and LA allergy have appeared in the published literature for several years. However, the incidence of true, IgE-mediated LA allergy remains uncertain and is presumed to be very low. We critically reviewed the English language literature on suspected LA allergy and its investigation with the aim of estimating the reported prevalence and analysing the role of different tests currently used to identify and confirm LA allergy. Twenty-three case series involving 2978 patients were identified and analysed. Twenty-nine of these patients had true IgE-mediated allergy to LA, thus confirming the reported prevalence of LA allergy in large series to be <1% (0.97%). The protocols used in the investigation of these patients have also been discussed. Evidence from this review confirms the rarity of IgE-mediated allergy to LA and supports an investigation strategy based on using the clinical history to select patients for skin testing and challenge. We believe that such a triage process would alleviate pressures on allergy services without compromising patient safety.
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Affiliation(s)
- M V Bhole
- Department of Immunology, Oxford University Hospitals NHS Trust, Academic Street, Level 4, John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK
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Thyssen JP, Menné T, Elberling J, Plaschke P, Johansen JD. Hypersensitivity to local anaesthetics--update and proposal of evaluation algorithm. Contact Dermatitis 2008; 59:69-78. [PMID: 18759873 DOI: 10.1111/j.1600-0536.2008.01366.x] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Local anaesthetics (LA) are widely used drugs. Adverse reactions are rare but may be caused by delayed-type hypersensitivity reactions and probably also immediate-type reactions. As it is not always easy to clinically differ between these subtypes, allergy skin testing should be considered. Although numerous test protocols have been published, how patients with hypersensitivity reactions to LA are ideally evaluated remains a topic of discussion. This review attempts to generate a comprehensive update on allergic reactions to LA and to present an algorithm that can be used for the evaluation of patients suspected with immediate- and delayed-type immune reactions. Literature was examined using PubMed-Medline, EMBASE, Biosis and Science Citation Index. Based on the literature, the proposed algorithm may safely and rapidly distinguish between immediate-type and delayed-type allergic immune reactions.
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Sánchez-Gutiérrez M, Delgado-Buenrostro NL, Zárate-Grande M, Uribe S, Mújica A. In guinea pig spermatozoa, the procaine-promoted synchronous acrosome reaction results in highly fertile cells exhibiting normal F-actin distribution. Reprod Toxicol 2006; 21:208-15. [PMID: 16309886 DOI: 10.1016/j.reprotox.2005.08.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2005] [Revised: 08/19/2005] [Accepted: 08/26/2005] [Indexed: 01/04/2023]
Abstract
In guinea pig spermatozoa, procaine induces Ca(2+) independent hyperactivated motility suggestive of sperm capacitation. Nonetheless, in the presence of high extracellular Ca(2+), procaine increases cytoplasmic Ca(2+). We analyze the procaine effect on the acrosome reaction (AR) processes in guinea pig spermatozoa. Results indicated that: (i) in spermatozoa pre-incubated 5-30 min in MCM-PLG medium, procaine produced synchronous AR, (ii) the acrosome-reacted sperm number increased with the capacitation period before procaine treatment and with procaine concentration, (iii) acrosome reaction was blocked when Ca(2+) was omitted, (iv) plasma membrane-outer acrosomal membrane fusion started within 2 min after procaine treatment, (v) in acrosome-reacted spermatozoa, actin polymerization occurred and F-actin was located in the equatorial and post-acrosomal regions and (vi) procaine treatment resulted in highly fertile acrosome-reacted spermatozoa. This is the first report indicating that procaine promotes synchronic AR in mammalian spermatozoa. If procaine promotes premature AR of spermatozoa in vivo, it might be a factor for infertility in patients exposed to this local anesthetic.
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Affiliation(s)
- Manuel Sánchez-Gutiérrez
- Departamento de Biología Celular, Centro de Investigación y de Estudios Avanzados del Instituto Politécnico Nacional, Apdo. Postal 14740, 07000 México D.F., México
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Dance D, Basti S, Koch DD. Use of preservative-free lidocaine for cataract surgery in a patient allergic to “caines”. J Cataract Refract Surg 2005; 31:848-50. [PMID: 15899466 DOI: 10.1016/j.jcrs.2004.09.059] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2004] [Indexed: 10/25/2022]
Abstract
Although many patients have been labeled allergic to local anesthetics (LAs), true allergic reactions to LAs are rare. An 81-year-old woman with a history of procaine (Novocaine) allergy presented for cataract surgery. Skin testing showed sensitivity to amide and ester LAs. Further testing with preservative-free lidocaine was negative, suggesting the patient was allergic to ester LAs and preservatives found in amide anesthetic preparations. Cataract extraction was subsequently and uneventfully performed in both eyes with topical anesthesia using preservative-free lidocaine.
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Affiliation(s)
- David Dance
- Baylor College of Medicine, Houston, Texas 77030, USA
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Prieto A, Herrero T, Rubio M, Tornero P, Baeza ML, Velloso A, Pérez C, De Barrio M. Urticaria due to mepivacaine with tolerance to lidocaine and bupivacaine. Allergy 2005; 60:261-2. [PMID: 15647053 DOI: 10.1111/j.1398-9995.2005.00648.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- A Prieto
- Servicio de Alergia, Hospital General Universitario Gregorio, Marañón, C/Dr. Esquerdo, 46, 28007 Madrid, Spain.
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Current World Literature. Curr Opin Allergy Clin Immunol 2004. [DOI: 10.1097/01.all.0000136752.28324.26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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