The effects of formulation and addition of adrenaline to cocaine for haemostasis in intranasal surgery

Topical Cocaine Hydrochloride Nasal Solution: Anesthetic and Surgical Considerations

Adequate surgical view during various types of nasal procedures is essential for surgical operations to be performed in a safe, efficient, and successful manner. Minimizing bleeding during surgery is an important way of increasing visualization that is commonly achieved by using a vasoconstrictive agent to control intraoperative hemorrhage. Many otolaryngologists choose to employ topical cocaine to minimize bleeding during surgery owing to its vasoconstrictive properties, while simultaneously benefitting from its dual local anesthetic effects. The relative benefit of topical cocaine for otolaryngologic procedures when compared to other topical analgesics and vasoconstrictors remains a topic of discussion due to the multiple potential cardiac and central nervous system side effects associated with cocaine administration. Furthermore, there is not a scientifically backed maximal safe dose published; instead, most of the guidelines for intranasal cocaine use are based on untested clinical practice. Despite this, the short latency, adequate duration of action, and inherent vasoconstrictive and decongestive capabilities make cocaine a valuable anesthetic agent for use in clinical procedures. As the relative benefit of using topical cocaine compared to the use of other vasoconstrictors and analgesics for nasal procedures remains undetermined in the current literature, this leaves the need for a comprehensive review of research that explores the risks and benefits of using topical cocaine in nasal procedures based on clinical trials that compare intranasal cocaine with various other analgesics and vasoconstrictors.

Medical use of cocaine and perioperative morbidity following sinonasal surgery-A population study

Background

Topical cocaine is favoured by many surgeons for sinonasal surgery due to its superior vasoconstrictive and anesthetic properties. However, historical reports suggesting cocaine is associated with an increased risk of cardiac events have led many surgeons to turn to alternative topical medications. The objective of this study was to determine whether cocaine use during sinonasal surgery is associated with an increased risk of perioperative cardiac events and death.

Methods

We conducted a population-based analysis of patients undergoing sinonasal surgery from 2009–2016 using linked administrative health care data sets in Ontario, Canada. We compared patients treated at institutions that primarily use topical cocaine (exposed group) to those treated at institutions that do not use cocaine (unexposed group). Our primary outcome was a composite of major cardiac events or all-cause mortality within 48 hours of surgery. Due to low event rates, the outcome was compared using a Fisher’s exact test.

Results

Of 10,549 patients who were included in the study, 27.4% were treated at an institution that uses topical cocaine. The rate of the composite of perioperative major cardiac event or all-cause mortality within 48 hours of surgery in the exposed and unexposed groups was, ≤0.2% and 0 (p-value>0.05), respectively.

Conclusions

In this large real-world cohort of patients undergoing sinonasal surgery, there does not appear to be any significant increased risk of morbidity or mortality associated with cocaine use. These findings have important implications for surgeons performing this procedure.

Topical Vasoconstrictors in Cosmetic Rhinoplasty: Comparative Evaluation of Cocaine Versus Epinephrine Solutions

BACKGROUND

The use of topical vasoconstrictors is a common practice in nasal surgery. These agents reduce bleeding and enable a good surgical field. Topical cocaine and epinephrine, which are frequently used in cosmetic rhinoplasty, are considered safe and effective, but secondary effects have been described. The aim of the present study was to evaluate and compare the benefits and risks of epinephrine and cocaine employed as topical vasoconstrictive agents in cosmetic rhinoplasty.

METHODS

This prospective non-randomised study included 65 consecutive female patients undergoing primary closed rhinoplasty. Patients were treated with topical aqueous solutions of 4 % cocaine (n = 33) or 1:1000 epinephrine (n = 32). Benefits and risks of drug use were compared between groups. Vasoconstriction was assessed by quantitative and qualitative evaluation of bleeding during surgery. Systemic effects were studied in terms of cardiovascular changes during the procedure. The Mann-Whitney test and mixed-effects models were used to compare continuous variables and to assess the effects of vasoconstrictor treatment, respectively.

RESULTS

Cocaine exerted a stronger and more predictable vasoconstrictive effect than epinephrine. This difference was linked to better field quality, but did not relate to shorter surgery times. Increased heart rate was detected with both agents and was significantly higher with cocaine (p < 0.05). Blood pressure did not significantly differ between groups.

CONCLUSIONS

Both cocaine and epinephrine, at the concentrations used in this study, are suitable as topical vasoconstrictive agents in aesthetic rhinoplasty.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Does epinephrine infiltration in septoplasty make any difference? A double blind randomised controlled trial

Infiltration of lignocaine with epinephrine is used with cocaine in septoplasty, in attempt to improve haemostasis and thereby improve the surgical field. This practice is widespread despite the lack of evidence to support its efficacy in the literature. Thirty patients undergoing septoplasty were randomised into two groups -- one in whom infiltration was performed with lignocaine (2%) with adrenaline (1:80,000) and a control group who received lignocaine (2%). Both groups of patients received intranasal application of cocaine paste prior to surgery. The surgeon and anaesthetist were blinded to the contents of the infiltration. The operative field was rated by the surgeon, and the blood loss calculated. No significant difference was demonstrated in blood loss or surgical field between the groups. However there was significant rise in systolic blood pressure in patients who received epinephrine. The use of epinephrine with cocaine paste does not improve haemostasis or surgical field. As the use of epinephrine is associated with cardiac arrhythmias, the authors suggest that combined use of cocaine paste and epinephrine infiltration should be avoided in septal surgery.

Does cocaine still have a role in nasal surgery?

Endonasal surgery is already very common and its importance is increasing. Successful anaesthesia in endonasal sinus surgery is of critical importance for the success of the procedure and many surgeons prefer to use cocaine for this purpose. However, there is a great body of evidence that suggests that use of cocaine, even in experienced hands, can cause rapid, unexpected and severe toxic reactions. Therefore, its use in endonasal surgery can no longer be recommended, especially since better tolerated alternatives are available for topical and infiltration anaesthesia. These alternatives include lidocaine (lignocaine) and tetracaine (pantocaine) in combination with epinephrine (adrenaline), naphazoline or oxymetazoline.

[Cocaine contact anesthesia for endonasal surgery. Kinetics and clinical tolerance of a concentrated solution]

OBJECTIVE

To assess the pharmacokinetics and clinical tolerance of a 33% cocaine solution administered topically for intranasal surgery.

STUDY DESIGN

Clinical prospective open trial.

PATIENTS AND METHODS

Twelve ASA I patients scheduled for intranasal surgery were sedated with midazolam 2 mg and fentanyl 50 micrograms. Topical anaesthesia was obtained with aqueous 33% cocaine HCl 360 mg, lidocaine HCl 140 mg, adrenaline 0.04 mg and naphazoline 0.4 mg. Venous blood samples were taken before cocaine application and 15, 30, 45, 60, 90, 120, 150, 180, 240 min later. The plasma was immediately separated and the samples were frozen. The concentration of cocaine was measured by HPLC. Potential cardiotoxic and neurotoxic effects were clinically monitored.

RESULTS

The mean dose of cocaine applied was 5.85 +/- 1.3 mg.kg-1 and the dose actually delivered was 4 +/- 1.5 mg.kg-1. The Cmax was 859 +/- 503 ng.mL-1 after a Tmax to 47 +/- 17 min. The mean elimination half-life was 87 +/- 19 min (mean +/- SD). The total clearance and the volume of distribution were respectively 4,521 +/- 1,858 mL.min-1 and 568 +/- 273 L. No clinical evidence of toxicity was found.

CONCLUSIONS

This study shows that it is possible to perform major intranasal surgery under topical anaesthesia with a concentrated solution (33%) of cocaine at a high dose (6 mg.kg-1). These results differ completely with data obtained in addicts.

Mechanism of action of some commonly used nasal drugs

This article provides a brief description of the mechanism of action of drugs commonly used in the treatment of nasal disorders. These include oral and topical vasoconstrictors, antihistamines, atropine-like drugs, cocaine, topical corticosteroids, and mast-cell stabilizers.