A Case Report of Prilocaine-Induced Methemoglobinemia after Liposuction Procedure

Abstract

Prilocaine-induced methemoglobinemia is a rarely seen condition. In this paper, a case is presented with methemoglobinemia developed secondary to prilocaine use in a liposuction procedure, and the importance of this rarely seen condition is emphasized. A 20-year-old female patient presented with complaints of prostration, lassitude, shivering, shortness of breath, and cyanosis. It was learned that the patient underwent nearly 1000 mg prilocaine infiltration 8 hours priorly during a liposuction procedure. At admission, her blood pressure (130/80 mmHg), pulse rate (140 bpm), body temperature (36°C), and respiratory rate (40/min) were recorded. The patient had marked acrocyanosis. The arterial blood gas methemoglobin level was measured as 40%. The patient received oxygen therapy with a mask and was administered vitamin C in normal saline (500 mg tid), N-acetylcysteine (300 mg tid), and 50 mg 10% methylene blue in the intensive care unit of the internal medicine department. Methemoglobin level dropped down to 2% after her treatment with methylene blue and she was clinically cured and discharged 2 days later. Emergency service physicians should remember to consider methemoglobinemia when making a differential diagnosis between dyspnea and cyanosis developing after prilocaine infiltration performed for liposuctions in the adult age group.

Anesthesia Management for Large-Volume Liposuction

“…These data show that articaine is safe for infiltration during liposuction [10]. The groups that have reported the use of prilocaine have not detected elevated levels of it in plasma or methemoglobinemia [11,12], although Yildirim et al described a patient with 40% methemoglobinemia that developed 8 h after liposuction was performed with almost 1000 mg of prilocaine [13]. In our surgical facility, the most used local anesthetic is lidocaine, and even though for other applications when used in association with epinephrine, the maximum limit is established at 7 mg/kg.…”

Methemoglobinemia in the Operating Room and Intensive Care Unit: Early Recognition, Pathophysiology, and Management

“…Of note, methylene blue increases the reducing capacity of the NADPH-MHb reductase system by acting as a cofactor in the electron transfer from NADPH to the oxidized methemoglobin [8]. Therefore, an adjuvant therapy to consider is ascorbic acid, which works by non-enzymatically reducing methemoglobin, although to a much lesser extent than methylene blue [11,20]. The substitution of ascorbic acid for methylene blue is necessary in circumstances where methylene blue is not available or is contraindicated.…”

“…In these patients, the use of methylene blue can worsen methemoglobinemia and promote red blood cell lysis. This is because the reduction of methemoglobin by methylene blue is dependent on NADPH generated by G6PD [20]. Methylene blue can also act by reversibly inhibiting monoamine oxidase A (MOA), leading to a rise in serotonin levels.…”

Acrocyanosis – A Symptom with Many Facettes

“…In severe cases, cyanosis, tachypnea, tachycardia, hypotension, confusion, or even death may be observed. Methemoglobinemia has been noted with all anaesthetics, such as lidocaine, prilocaine or ripivocaine, and patient safety demands laboratory monitoring of methemoglobin [ 35 ].…”