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Tetracaine's Bad Reputation Is Not Well Deserved: Response
Momen M. Wahidi, MD, MBA, FCCP Durham, NC Pyng Lee, MD, FCCP Singapore, Singapore
© 2012 American College g of Chest Physicians. y Reproduction p of this article is p prohibited without written p permission from the American College g of Chest Physicians. y See online for more details. DOI: 10.1378/chest.12-0153
References 1. Wahidi MM, Jain P, Jantz M, et al. American College of Chest Physicians consensus statement on the use of topical anesthesia, analgesia, and sedation during flexible fl bronchoscopy in adult patients. Chest. 2011;140(5):1342-1350. 2. Credle WF Jr, Smiddy JF, Elliott RC. Complications of fiberoptic bronchoscopy. Am Rev Respir Dis. 1974;109(1): 67-72. 3. Suratt PM, Smiddy JF, Gruber B. Deaths and complications associated with fiberoptic bronchoscopy. Chest. 1976;69(6): 747-751. 4. Feinsilver SH, Fein AM. Textbook of Bronchoscopy. Baltimore, MD: Wilkins and Williams; 1995. 5. Colt HG, Matsuo T. Hospital charges attributable to bronchoscopy-related complications in outpatients. Respiration. 2001;68(1):67-72. 6. Davis KL, Channick CL. Safety of topical tetracaine in patients undergoing flexible fl bronchoscopy. J Bronch Intervent Pulmonol. 2009;16(2):95-98. 7. Guay J. Methemoglobinemia related to local anesthetics: a summary of 242 episodes. Anesth Analg. 2009;108(3):837-845.
Response To the Editor: We appreciate the comments from Dr Davis about our recent consensus statement in CHEST T1 and his concerns regarding our association of tetracaine with methemoglobinemia. Methemoglobinemia is a serious adverse event that has been reported to occur with multiple topical anesthetics including benzocaine, prilocaine, lidocaine, and tetracaine.2 Benzocaine is by far the most commonly reported agent with respect to association with methemoglobinemia, which could occur in a dose-independent fashion, even after a single benzocaine spray.2 The US Food and Drug Administration has issued multiple Public Health Advisory warnings about methemoglobinemia with the use of benzocaine sprays during medical procedures.3 Although the literature suggests a lower association of methemoglobinemia with tetracaine, the risk still exists and its nature is further confounded by the popularity of a particular pharmaceutical preparation, Cetacaine, containing benzocaine 14%, butyl aminobenzoate 2%, and tetracaine 2%, making it difficult to separate the action of the two drugs. Numerous reports have reported on the association of Cetacaine and methemoglobinemia and have discouraged its use in medical procedures.4-6 We agree with Dr Davis that all the topical anesthetic agents used during flexible bronchoscopy have the potential for toxicity. Our goal was to alert the chest physician to the risk of methemoglobinemia but we could have better delineated the attributed risk to different topical anesthetic agents. However, the data surrounding this differential risk with various agents are scant, and our panel felt the need to increase the general alertness to a potentially very serious condition. A consensus statement is not designed to provide evidencebased practice guidelines, but rather, suggestions for good clinical practice and a forum for debate.7 This is exactly what this letter to the editor and response are embodying. www.chestpubs.org
Affi filiations: From the Department p of Medicine (Dr Wahidi) Duke Universityy Medical Center; and the National University Hospital p (Dr Lee). Financial/nonfi financial disclosures: Dr Wahidi was an investigator g on the multicenter trial of Fospropofol. p p Dr Lamb has been an Educational Board Consultant for the following: g Boston Scientific fi 2007 to current, Cardinal Health 2007 and 2008, and Super p Dimension 2007. Dr Lee has reported p to CHEST T that no potential conflicts of interest exist with anyy companies/orgap p g nizations whose products or services may be discussed in this article. Correspondence p to: Momen M. Wahidi, MD, MBA, FCCP, Department p of Internal Medicine, Division of Pulmonary, y Allergy, gy and Critical Care Medicine, Duke Universityy Medical Center, Box 3683, Durham, NC 27710; e-mail: [email protected] © 2012 American College g of Chest Physicians. y Reproduction p of this article is p prohibited without written p permission from the American College g of Chest Physicians. y See online for more details. DOI: 10.1378/chest.12-0754
References 1. Wahidi MM, Jain P, Jantz M, et al. American College of Chest Physicians consensus statement on the use of topical anesthesia, analgesia, and sedation during flexible fl bronchoscopy in adult patients. Chest. 2011;140(5):1342-1350. 2. Guay J. Methemoglobinemia related to local anesthetics: a summary of 242 episodes. Anesth Analg. 2009;108(3):837-845. 3. US Department of Health and Human Services. FDA’s information for healthcare professionals. US Food and Drug Administration website. http://www.fda.gov/downloads/Drugs/ DrugSafety/PostmarketDrugSafetyInformationforPatientsand Providers/UCM274557.pdf. Accessed March 21, 2012. 4. Byrne MF, Mitchell RM, Gerke H, et al. The need for caution with topical anesthesia during endoscopic procedures, as liberal use may result in methemoglobinemia. J Clin Gastroenterol. 2004;38(3):225-229. 5. Gregory PJ, Matsuda K. Cetacaine spray-induced methemoglobinemia after transesophageal echocardiography. Ann Pharmacother. r 2000;34(9):1077. 6. Khan NA, Kruse JA. Methemoglobinemia induced by topical anesthesia: a case report and review. Am J Med Sci. 1999; 318(6):415-418. 7. Baumann MH, Gutterman DD. American College of Chest Physicians evidence-based guidelines—the next generation: considering resource use and evolution to a single grading system. Chest. 2006;129(1):10-12.
Early Mobilization Testing in Patients With Acute Stroke To the Editor: For the past 11 years, we have been studying very early mobilization (EM) (out of bed) in people with acute stroke. The elegant review by Schweickert and Kress1 in a recent issue of CHEST (December 2011) of the emerging research on EM of patients treated in the ICU brought home the parallels that exist between EM research, regardless of the population studied. Inactivity, at least in the first days to weeks, appears to be the norm after having a stroke or being managed in the ICU. CHEST / 141 / 6 / JUNE, 2012
Downloaded from chestjournal.chestpubs.org by Kimberly Henricks on June 5, 2012 © 2012 American College of Chest Physicians
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© 2012 American College g of Chest Physicians. y Reproduction p of this article is p prohibited without written p permission from the American College g of Chest Physicians. y See online for more details. DOI: 10.1378/chest.12-0153
References 1. Wahidi MM, Jain P, Jantz M, et al. American College of Chest Physicians consensus statement on the use of topical anesthesia, analgesia, and sedation during flexible fl bronchoscopy in adult patients. Chest. 2011;140(5):1342-1350. 2. Credle WF Jr, Smiddy JF, Elliott RC. Complications of fiberoptic bronchoscopy. Am Rev Respir Dis. 1974;109(1): 67-72. 3. Suratt PM, Smiddy JF, Gruber B. Deaths and complications associated with fiberoptic bronchoscopy. Chest. 1976;69(6): 747-751. 4. Feinsilver SH, Fein AM. Textbook of Bronchoscopy. Baltimore, MD: Wilkins and Williams; 1995. 5. Colt HG, Matsuo T. Hospital charges attributable to bronchoscopy-related complications in outpatients. Respiration. 2001;68(1):67-72. 6. Davis KL, Channick CL. Safety of topical tetracaine in patients undergoing flexible fl bronchoscopy. J Bronch Intervent Pulmonol. 2009;16(2):95-98. 7. Guay J. Methemoglobinemia related to local anesthetics: a summary of 242 episodes. Anesth Analg. 2009;108(3):837-845.
Response To the Editor: We appreciate the comments from Dr Davis about our recent consensus statement in CHEST T1 and his concerns regarding our association of tetracaine with methemoglobinemia. Methemoglobinemia is a serious adverse event that has been reported to occur with multiple topical anesthetics including benzocaine, prilocaine, lidocaine, and tetracaine.2 Benzocaine is by far the most commonly reported agent with respect to association with methemoglobinemia, which could occur in a dose-independent fashion, even after a single benzocaine spray.2 The US Food and Drug Administration has issued multiple Public Health Advisory warnings about methemoglobinemia with the use of benzocaine sprays during medical procedures.3 Although the literature suggests a lower association of methemoglobinemia with tetracaine, the risk still exists and its nature is further confounded by the popularity of a particular pharmaceutical preparation, Cetacaine, containing benzocaine 14%, butyl aminobenzoate 2%, and tetracaine 2%, making it difficult to separate the action of the two drugs. Numerous reports have reported on the association of Cetacaine and methemoglobinemia and have discouraged its use in medical procedures.4-6 We agree with Dr Davis that all the topical anesthetic agents used during flexible bronchoscopy have the potential for toxicity. Our goal was to alert the chest physician to the risk of methemoglobinemia but we could have better delineated the attributed risk to different topical anesthetic agents. However, the data surrounding this differential risk with various agents are scant, and our panel felt the need to increase the general alertness to a potentially very serious condition. A consensus statement is not designed to provide evidencebased practice guidelines, but rather, suggestions for good clinical practice and a forum for debate.7 This is exactly what this letter to the editor and response are embodying. www.chestpubs.org
Affi filiations: From the Department p of Medicine (Dr Wahidi) Duke Universityy Medical Center; and the National University Hospital p (Dr Lee). Financial/nonfi financial disclosures: Dr Wahidi was an investigator g on the multicenter trial of Fospropofol. p p Dr Lamb has been an Educational Board Consultant for the following: g Boston Scientific fi 2007 to current, Cardinal Health 2007 and 2008, and Super p Dimension 2007. Dr Lee has reported p to CHEST T that no potential conflicts of interest exist with anyy companies/orgap p g nizations whose products or services may be discussed in this article. Correspondence p to: Momen M. Wahidi, MD, MBA, FCCP, Department p of Internal Medicine, Division of Pulmonary, y Allergy, gy and Critical Care Medicine, Duke Universityy Medical Center, Box 3683, Durham, NC 27710; e-mail: [email protected] © 2012 American College g of Chest Physicians. y Reproduction p of this article is p prohibited without written p permission from the American College g of Chest Physicians. y See online for more details. DOI: 10.1378/chest.12-0754
References 1. Wahidi MM, Jain P, Jantz M, et al. American College of Chest Physicians consensus statement on the use of topical anesthesia, analgesia, and sedation during flexible fl bronchoscopy in adult patients. Chest. 2011;140(5):1342-1350. 2. Guay J. Methemoglobinemia related to local anesthetics: a summary of 242 episodes. Anesth Analg. 2009;108(3):837-845. 3. US Department of Health and Human Services. FDA’s information for healthcare professionals. US Food and Drug Administration website. http://www.fda.gov/downloads/Drugs/ DrugSafety/PostmarketDrugSafetyInformationforPatientsand Providers/UCM274557.pdf. Accessed March 21, 2012. 4. Byrne MF, Mitchell RM, Gerke H, et al. The need for caution with topical anesthesia during endoscopic procedures, as liberal use may result in methemoglobinemia. J Clin Gastroenterol. 2004;38(3):225-229. 5. Gregory PJ, Matsuda K. Cetacaine spray-induced methemoglobinemia after transesophageal echocardiography. Ann Pharmacother. r 2000;34(9):1077. 6. Khan NA, Kruse JA. Methemoglobinemia induced by topical anesthesia: a case report and review. Am J Med Sci. 1999; 318(6):415-418. 7. Baumann MH, Gutterman DD. American College of Chest Physicians evidence-based guidelines—the next generation: considering resource use and evolution to a single grading system. Chest. 2006;129(1):10-12.
Early Mobilization Testing in Patients With Acute Stroke To the Editor: For the past 11 years, we have been studying very early mobilization (EM) (out of bed) in people with acute stroke. The elegant review by Schweickert and Kress1 in a recent issue of CHEST (December 2011) of the emerging research on EM of patients treated in the ICU brought home the parallels that exist between EM research, regardless of the population studied. Inactivity, at least in the first days to weeks, appears to be the norm after having a stroke or being managed in the ICU. CHEST / 141 / 6 / JUNE, 2012
Downloaded from chestjournal.chestpubs.org by Kimberly Henricks on June 5, 2012 © 2012 American College of Chest Physicians
1641