Hypersensitivity to local anesthetics

Thyssen JP. Menne T. Elberberg J. Plaschke P, 16 Johansen D Hypersensitivity to local anesthetics -update and proposal of evaluation algorithm. Contact Dermatitis 2008 59 69-78. 17... 

IM Hypersensitivity to local anesthetics of the amide type and in patients with severe shock or heart block due to the use of lidocaine hydrochloride diluent. 

Contraindications include hypersensitivity to local anesthetics of the amide type (a very rare occurrence), severe hepatic dysfunction, a history of grand mal seizures due to lidocaine, and age 70 or older. Lidocaine is contraindicated in the presence of second- or third-degree heart block, since it may increase the degree of block and can abolish the idioventricular pacemaker responsible for maintaining the cardiac rhythm. 

Contraindications Hypersensitivity to local anesthetics, second- or third-degree AV block... 

Systemic hypersensitivity reactions are not a frequent problem in local anesthesia. Systemic toxicity or allergy to additives (hyaluronidase, bisulfate, parabens) has sometimes been mistakenly classified as hypersensitivity to local anesthetics (SEDA-17,135) (29). WeU-documented case reports are very few, relating particularly to the older aminoesters this appears to be because these agents have the highly antigenic para-aminobenzoic acid as a metabolite (SEDA-13, 98). The incidence of true allergy is actually very low, probably less than 1% of all the adverse effects attributable to these substances (SEDA-20, 123). 

When injected into the skin, local anesthetics often cause pseudo-allergic reactions, with similar symptoms to immediate type allergy (42). However, true immediate hypersensitivity to local anesthetics is extremely rare. 

Hypersensitivity to local anesthetics appears to be related to both chemical structure and the method of administration. Allergic reactions occur most frequently with csler-ba.sed local anesthetic agents (benzoic acid derivatives). Adverse effects include allergic dermatitis, asthmatic attack, or. in extreme cases, death due to anaphylactic shock. Individuals suffering a hypersensitive reaction from one local anesthetic agent are often sensitive to compounds with a. similar structure. For example, patients semsilive to procaine arc often also sensitive to amethocaine... 

In contrast, allergic reactions to local anesthetics, although rare, are known to occur exclusively with p-aminobenzoic ester-type local anesthetics (18). Whether the formation of PABA on ester hydrolysis is solely responsible for this hypersensitivity remains to be investigated. However, the preservative compounds, such as methyparaben, used in the preparation of amide-type local anesthetics are metabolized to PABA-like substance, p-hydroxybenzoic acid. Thus, patients who are allergic to amino ester-type local anesthetics should be treated with a preservative-free amino amide-type local anesthetic. 

Following the first description of allergy to a local anesthetic over 90 years ago, there was initially a steady stream of reports of reactions to the drugs consisting mainly of erythema or edema. With the introduction of the amide local anesthetics, the number of hypersensitivity reactions tapered off significantly, indicating that ester compounds were less well tolerated. Even today, however, reports of adverse reactions to local anesthetics occasionally appear, but the nature of the reactions cannot always be described... 

IgE antibodies to local anesthetics appear to be so rare that some have even doubted that they occur, but occasional case reports indicate an underlying mechanism of type 1 hypersensitivity and some skin test results suggest that these antibodies do exist. Evidence from a dot-blot procedure for an IgE-mediated reaction to lignocaine has been presented, and more recently, IgE antibodies to mepivacaine were reliably detected by a Phadia immunoassay shown by inhibition studies to be specific. 

De Shazo RD, Nelson HS An approach to the 38 patient with a history of local anesthetic hypersensitivity experience with 90 patients. J Allergy Chn Immunol 1979 63 387-394. 

It is used in anaphylactic, allergic, and other hypersensitive reactions, as an agent to increase blood pressure in hypotension, as a broncholytic in pulmonary edema, as an antiedema agent in othorinolaringology (LOR) and in ophthahnological practice, and also to prolong the action of local anesthetics. 

Hypersensitivity reactions In patients sensitive to procaine or other ester-type local anesthetics, cross-sensitivity to procainamide is unlikely however, consider the possibility. Do not use procainamide if it produces acute allergic dermatitis, asthma or anaphylactic symptoms. 

Hypersensitivity to amide local anesthetics Stokes-Adams syndrome Wolff-Parkinson-White syndrome severe degrees of sinoatrial, atrioventricular (AV), or intraventricular block in the absence of an artificial pacemaker. 

Hypersensitivity to sulfonamides or chemically related drugs (eg, sulfonylureas, thiazide and loop diuretics, carbonic anhydrase inhibitors, sunscreens with PABA, local anesthetics) pregnancy at term lactation infants less than 2 months of age (except in congenital toxoplasmosis as adjunct with pyrimethamine) porphyria salicylate hypersensitivity. 

Benzonatate (Tessalon) is related to the local anesthetic tetracaine. It anesthetizes the stretch receptors in the lungs, thereby reducing coughing. Adverse reactions include hypersensitivity, sedation, dizziness, and nausea. 

Contraindications Hypersensitivity to benzocaine or ester-type local anesthetics, perforated tympanic membrane or ear discharge (otic preparations)... 

Contraindications History of hypersensitivity to beta-lactams (imipenem and cilas-tin, meropenem), hypersensitivity to amide-type local anesthetics (IM)... 

Contraindications Adams-Stokes syndrome, hypersensitivity to amide-type local anesthetics, septicemia (spinal anesthesia), supraventricular arrhythmias, Wolff-Par-kinson-White syndrome... 

Contraindications Hypersensitivity to esther local anesthetics, sulfites, PABA, infection or inflammation at the injection site, bacteremia, platelet abnormalities, thrombocytopenia, increased bleeding time, uncontrolled coagulopathy, anticoagulant therapy, sulfonamide therapy. 

Contraindications Hypersensitivity to benzocaine or similar local anesthetics... 

The ease of application, the minimization of systemic side effects, and the increased drug penetration directly into the target region resulted in extensive clinical use of iontophoresis mainly in the transdermal field. This technique has been utilized for administration of local anesthetics [2-5], sweat chloride testing in cystic fibrosis patients by transcutaneous delivery of pilocarpine [6,7], administration of vidarabine to patients with herpes orolabialis [8], fluoride administration to patients with hypersensitive dentin [9,10], and gentamicin delivery for the management of burned ears [11],... 

The ester-containing local anesthetics become metabolized to p-aminobenzoic acid derivatives, which have a potential for causing hypersensitivity reactions. Allergic reactions to amide are... 

Hypersensitivity to benzalkonium chloride has been reported in association with the use of ophthalmic medications. Because several of the commonly used topical ocular anesthetics contain benzalkonium as a preservative (see Table 6-2), it is reasonable to assume that some of the local allergic reactions to anesthetics may be due to this preservative. 

Most local anesthetic preparations contain benzo-caine. Because benzocaine is poorly absorbed through the skin, it remains localized for a long time however, its effectiveness is unpredictable. Benzocaine has also been known to produce local hypersensitivity reactions.f ... 

In a survey of 100 000 bronchograms published in 1967, 18 deaths were attributed to the technique. However, half of the deaths were due to the local anesthetic, generally used in excessive amounts. Fatalities tended to occur in children, patients with limited respiratory reserves, or subjects with severe hypersensitivity reactions (SED-12,1185) (286). 

Hypersensitivity reactions are rare, and not all reports are clear, but cases do occur and are usually mild (SED-12, 255) (4). Some patients are highly sensitive to lidocaine, yet insensitive to other aminoamide local anesthetics (5), and the reverse has also been found (SEDA-14, 109). True anaphylaxis with rechallenge has been documented (6). A few cases of contact dermatitis have been reported. 

Some distinction must be made between the main groups of local anesthetics as to the frequency of complications. Hypersensitivity reactions, for example, are relatively less common with the aminoamides, such as bupivacaine, cinchocaine, etidocaine, lidocaine, mepivacaine, prilocaine, and ropivacaine, than with the amino-esters. However, the systemic toxic effects of individual local anesthetics differ bupivacaine, cinchocaine, and tetracaine are the most toxic. Furthermore, the individual characteristics of the patient (for example age, sex, body weight, and cardiac, renal, and hepatic function) are important (SEDA-17,134). 

Allergic reactions to aminoamide local anesthetics are unusual, but type I hypersensitivity reactions are described, and life-threatening anaphylaxis can rarely occur (SEDA-21, 136) (SEDA-22, 134). Cross-reaction between amides also occurs, for example articaine, bupi-vacaine, lidocaine, and prilocaine (SEDA-22,134). 

Contact hypersensitivity also occurs. Benzocaine is a potent skin sensitizer, and several cases of contact dermatitis to lidocaine have been reported. In many cases there is no cross-reactivity between different local anesthetics. 

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