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Oishi T, Kashiura M, Yasuda H, Kishihara Y, Tominaga K, Tamura H, Moriya T. Naphazoline intoxication managed with minimally invasive cardiac output monitoring. Am J Emerg Med 2024; 77:233.e5-233.e7. [PMID: 38155033 DOI: 10.1016/j.ajem.2023.12.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 12/22/2023] [Accepted: 12/22/2023] [Indexed: 12/30/2023] Open
Abstract
Naphazoline, a nonspecific alpha-adrenoceptor stimulant, is a potent vasoconstrictor used in nasal sprays, eye drops, and over-the-counter antiseptics. Naphazoline intoxication increases afterload by constricting the peripheral arteries, which can lead to complications including multiple organ failure. Although phentolamine, a nonselective alpha-adrenoceptor antagonist, and nicardipine, a calcium channel blocker, are used for the treatment of naphazoline intoxication, no established administration protocols currently exist. We present the case of a 32-year-old male with depression who ingested 150 mL of an antiseptic containing 0.1% naphazoline (equivalent to 150 mg of naphazoline). Five hours after ingestion, the patient was admitted to hospital exhibiting signs of naphazoline intoxication, such as bradycardia (46 beats/min), blood pressure of 166/122 mmHg, and peripheral cyanosis. We used the FloTrac™/EV1000™ system (Edwards Lifesciences, Irvine, CA, USA), a minimally invasive cardiac output monitoring system, to monitor systemic vascular resistance. The systemic vascular resistance index (SVRI) was elevated (4457 dyne.s/cm5/m2; nomal range: 1970-2390 dyne.s/cm5/m2) upon admission and initial treatment with continuous intravenous infusion of phentolamine led to SVRI normalization within 2 h. With the goal of maintaining SVRI normalization, continuous infusion with nicardipine was then started. At 10 h after treatment initiation, the nicardipine dose peaked at 9 mg/h (1.9 μg/kg/min). Treatment was discontinued 8 h later, and the patient was discharged on the fourth day without sequelae. In conclusion, the use of a minimally invasive cardiac output monitoring system to track vascular resistance can effectively guide the dosing of phentolamine or nicardipine in the treatment of naphazoline intoxication.
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Affiliation(s)
- Takatoshi Oishi
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Masahiro Kashiura
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan.
| | - Hideto Yasuda
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Yuki Kishihara
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Keiichiro Tominaga
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan.
| | - Hiroyuki Tamura
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Takashi Moriya
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan.
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Tissue Hypoperfusion, Hypercoagulopathy, and Kidney and Liver Dysfunction after Ingestion of a Naphazoline-Containing Antiseptic. Case Rep Emerg Med 2017; 2017:3968045. [PMID: 28555165 PMCID: PMC5438838 DOI: 10.1155/2017/3968045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 04/15/2017] [Accepted: 04/20/2017] [Indexed: 11/18/2022] Open
Abstract
Naphazoline is a peripheral α2-adrenergic receptor agonist commonly used as a topical decongestant. In Japan, over-the-counter antiseptics often contain naphazoline to effect local hemostasis. We present the first case involving the development of hypercoagulopathy, with kidney and liver dysfunction, following a naphazoline overdose. A 22-year-old Japanese woman with a history of depression ingested 160 mL of a commercially available antiseptic containing 0.1% naphazoline. Three days later, she was brought to the emergency department because of general fatigue, nausea, and vomiting. Physical examination revealed cool, pale extremities. Laboratory data showed evidence of severe kidney and liver dysfunction (creatinine, 9.2 mg/dL; alanine aminotransferase, 2948 IU/L), hypercoagulation (D-dimers, 58.3 μg/mL), and thrombocytopenia (platelet count, 90,000/μL). After infusion of normal saline, intravenous administration of alprostadil, and hemodiafiltration, her organ function completely recovered. Because both the kidney and liver express α2-adrenergic receptors, their failure was likely associated with naphazoline overdose-induced hypoperfusion. The most plausible causes of hypercoagulation are peripheral low perfusion and subsequent microthrombus formation. This case illustrates that severe organ dysfunction can occur following over-the-counter antiseptic ingestion and serves as a caution for both drug manufacturers and healthcare professionals.
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Novais T, Bourdelin M, Le Vavasseur O, Bontemps H. [Malignant hypertension and cardiac decompensation after overuse of nasal decongestant: A case report and literature review]. Rev Med Interne 2015; 37:424-8. [PMID: 26526778 DOI: 10.1016/j.revmed.2015.09.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 08/31/2015] [Accepted: 09/26/2015] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Vasoconstrictors, widely prescribed in the congestive states during acute rhinitis, are responsible for many cases of drug-related iatrogenic disease. CASE REPORT We report the case of a 40-year-old man, who presented with an episode of malignant hypertensive crisis associated with life-threatening congestive heart decompensation. The patient interview revealed consumption to supra-therapeutic dosage of an association of naphazoline and prednisolone nasal sprays. The diagnostic work-up allowed to rule out disease-related causes of secondary hypertension. The drug-related disease was thus retained. CONCLUSION The results of the literature review showed many cases of vasoconstrictor poisoning responsible for central nervous system and cardiovascular involvement, especially in young children. This first case of heart failure related to nasal decongestant administration increases the scope of potentially serious risks of these drugs and demonstrates the outreach needs for health professionals and patients about their proper use.
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Affiliation(s)
- T Novais
- Pharmacie, hôpital Nord-Ouest, BP 436, 69655 Villefranche-sur-Saône, France.
| | - M Bourdelin
- Pharmacie, hôpital Nord-Ouest, BP 436, 69655 Villefranche-sur-Saône, France
| | - O Le Vavasseur
- Service de cardiologie, hôpital Nord-Ouest, BP 436, 69655 Villefranche-sur-Saône, France
| | - H Bontemps
- Pharmacie, hôpital Nord-Ouest, BP 436, 69655 Villefranche-sur-Saône, France
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Latham GJ, Jardine DS. Oxymetazoline and hypertensive crisis in a child: can we prevent it? Paediatr Anaesth 2013; 23:952-6. [PMID: 23679077 DOI: 10.1111/pan.12192] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/18/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Oxymetazoline nasal spray is not FDA approved for use in children less than 6 years; however, its safety and efficacy are widely accepted, and it is in widespread use in children prior to procedures that may lead to epistaxis. We report a case of intraoperative oxymetazoline toxicity in a 4-year-old boy that led to a hypertensive crisis. While examining the possible causes for this problem, we became aware that the method of drug delivery led to an unanticipated overdose. The position in which the bottle is held causes pronounced variation in the quantity of oxymetazoline dispensed. METHODS To examine the impact that bottle position has on the volume delivered, we measured the volume of oxymetazoline dispensed with the bottle in the upright and inverted position. We also measured the volume of a drop of oxymetazoline dispensed from the bottle. Because an additional source of oxymetazoline exposure is from packing the nares with surgical pledgets, we analyzed the volume of oxymetazoline absorbed by each pledget. RESULTS Squeezing the bottle in the upright position results in a fine spray of fluid that averaged 28.9 ± 6.8 μl and was largely independent of effort. This volume is nearly identical to the measured volume of a drop of oxymetazoline, which was 30 μl. However, squeezing the bottle in the inverted position resulted in a steady stream of fluid, and the volume administered was completely effort dependent. Multiple tests in the inverted position demonstrated an average volume of 1037 ± 527 μl, with a range of 473-2196 μl. Lastly, the volume of oxymetazoline absorbed by each surgical pledget was 1511 ± 184 μl. DISCUSSION Our testing indicates that bottle position during oxymetazoline administration can cause up to a 75-fold increase in intended drug administration.
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Affiliation(s)
- Gregory J Latham
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA 98105, USA.
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Pulmonary edema and prolonged awakening after nasal naphazoline application in a transspenoidal hypophysectomy patient. J Neurosurg Anesthesiol 2010; 22:269. [PMID: 20548172 DOI: 10.1097/ana.0b013e3181dcb5b8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Granier M, Dadure C, Bringuier S, Bonnet-Boyer MC, Ryckwaert Y, Loriaux E, Capdevila X. Intranasal lidocaine plus naphazoline nitrate improves surgical conditions and perioperative analgesia in septorhinoplasty surgery. Can J Anaesth 2009; 56:102-8. [DOI: 10.1007/s12630-008-9020-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2008] [Revised: 11/05/2008] [Accepted: 11/13/2008] [Indexed: 10/20/2022] Open
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Fukushima H, Norimoto K, Seki T, Nishiguchi T, Nakamura T, Konobu T, Nishio K, Okuchi K. Acute pulmonary edema associated with naphazoline ingestion. Clin Toxicol (Phila) 2008; 46:254-6. [PMID: 17852165 DOI: 10.1080/15563650701438441] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
In published reports of naphazoline ingestion, clinical effects are hypertension, bradycardia, pallor, diaphoresis, and respiratory distress. We report three cases of acute pulmonary edema after the intentional ingestion of naphazoline-containing antiseptic first aid liquid. These cases presented with altered mental status, hypertension, bradycardia, and diaphoresis. Chest x-ray on admission revealed acute pulmonary edema. Two cases required mechanical ventilation. All of these clinical effects resolved within 24 hours and the patients were discharged with no sequelae. Since naphazoline stimulates the peripheral alpha-2 adrenergic receptor, we speculate that intense vasoconstriction may have elevated cardiac afterload and left atrial-ventricular blood volume and caused acute pulmonary edema.
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Affiliation(s)
- Hidetada Fukushima
- Department of Emergency and Critical Care Medicine, Nara Medical University, 840 Shijou cho, Kashihara City, Japan.
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Cohen-Kerem R, Ratnapalan S, Djulus J, Duan X, Chandra RV, Ito S. The attitude of physicians toward cold remedies for upper respiratory infection in infants and children: a questionnaire survey. Clin Pediatr (Phila) 2006; 45:828-34. [PMID: 17041170 DOI: 10.1177/0009922806295281] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Over-the-counter cold remedies are widely used for symptomatic relief of upper respiratory tract infections. The safety of these drugs is not well established in infants and their efficacy is questionable. Our aim was to study the attitude of family physicians and pediatricians toward the use of cold remedies in infants and children. A questionnaire was sent to 400 family physicians and 100 pediatricians randomly selected across Ontario. The overall response rate was 53.2%. Sixteen percent of family physicians recommended cold remedies for infants 0 to 6 months of age compared to 4% of the pediatricians (P = 0.01). For infants 6 to 12 months of age, the difference between pediatricians and family physicians persisted (14% and 38% of, respectively; P < 0.001). Despite that cold remedies are not proven to be effective and some safety issues are associated with their use in the pediatric age group, physicians still recommend them. Continuing medical education programs should address the issue.
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Affiliation(s)
- Raanan Cohen-Kerem
- Division of Clinical Pharmacology and Toxicology, Department of Pediatrics, University of Toronto, Hospital for Sick Children, Toronto, Ontario, Canada
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[Cardiac arrest and secondary pulmonary oedema following accidental intramucosal injection of naphazoline in an adult]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2003; 22:477-80. [PMID: 12831977 DOI: 10.1016/s0750-7658(03)00098-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
During neurosurgery for hypophysary adenoma under general anaesthesia in a prone position, a 34 year-old-women received accidental 6 ml intramucosal injection of lidocaine with naphazoline. The patient presented a severe bradycardia associated with a major increase in arterial blood pression followed by a brief cardiac arrest. She also presented a prolonged awakening and a pulmonary oedema, which lead to mechanical ventilation. The patient rapidly recovered a normal clinical state.
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