Oxymetazoline and hypertensive crisis in a child: can we prevent it?

Latham, Gregory J.; Jardine, David S.

doi:10.1111/pan.12192

Cited by 25 publications

(28 citation statements)

References 26 publications

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“…When administered in large doses or rapidly absorbed, oxymetazoline can be associated with systemic and pulmonary hypertension . Despite this concern, the PKs and PDs of oxymetazoline in children are not well understood, and associated intraoperative hemodynamic effects have not been previously characterized.…”

Section: Discussionmentioning

confidence: 99%

“…Given these effects, it is commonly used by otolaryngologists to produce vasoconstriction, thereby limiting blood loss and improving surgical field visualization during functional endoscopic sinus surgery (FESS), turbinate surgery, and adenoidectomy . Although there is generally limited vascular absorption when oxymetazoline is administered in larger doses, or when there is increased uptake due to vascular injury, this drug can lead to systemic hemodynamic effects including systemic and pulmonary hypertension . These events can cause hemodynamic instability, profound bradycardia, pulmonary edema, and cardiac arrest.…”

Section: Introductionmentioning

confidence: 99%

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Hemodynamic and pharmacokinetic analysis of oxymetazoline use during nasal surgery in children

et al. 2019

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Objectives/Hypothesis: Oxymetazoline is an α-adrenergic agonist that is commonly used as a topical hemostatic agent in the operating room during ear, nose, and throat surgery. There are limited data on oxymetazoline pharmacokinetics in children who undergo general anesthesia. We assessed the hemodynamic effects and systemic absorption of topically applied oxymetazoline in children undergoing various nasal procedures. Study Design: Prospective trial. Methods: Children ages 2 to 17 years undergoing functional endoscopic sinus surgery, turbinate resection, or adenoidectomy were enrolled. The surgeon placed oxymetazoline-soaked pledgets (1.5 mL of 0.05% solution) according to our usual clinical practice. Blood samples for oxymetazoline assay were drawn at 5, 10, 20, 45, 90, and 150 minutes, and hemodynamic data were recorded at 5-minute intervals. Data analysis included mixed-effects regression and population pharmacokinetic/pharma-codynamic modeling. Results: The analysis included 27 patients, age 7 ± 4 years, who received between 2 and 12 pledgets (3–18 mL) of oxymetazoline. Relative bioavailability compared to the spray formulation was 2.3 (95% confidence interval [CI]: 1.6–3.2), with slow absorption from the mucosal surface (absorption half-life 64 minutes; 95% CI: 44–90). Mean arterial pressure did not increase with oxymetazoline instillation at the observed oxymetazoline serum concentrations (0.04–7.6 μg/L). Conclusions: Despite concerns regarding oxymetazoline administration to mucosal membranes, we found that hemodynamic changes were clinically negligible with our usual clinical use of pledgets soaked in oxymetazoline. Compared to data on oxymetazoline in spray formulation, bioavailability was increased twofold with pledgets, but systemic absorption was very slow, contributing to low serum concentrations and limited hemodynamic effects.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Hemodynamic and pharmacokinetic analysis of oxymetazoline use during nasal surgery in children

et al. 2019

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“…However, these adverse events may have no relationship to preexisting hypertension, particularly given that they are most commonly reported in children (24, 26, 33). Importantly, the study excluded children and adults with hypertension, the 2 groups most in need of further study.…”

Section: Discussionmentioning

confidence: 99%

Effect of Intranasal Vasoconstrictors on Blood Pressure: A Randomized, Double-Blind, Placebo-Controlled Trial

Nichols

et al. 2018

The Journal of Emergency Medicine

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Background: Treatment for epistaxis includes application of intranasal vasoconstrictors. These medications have a precaution against use in patients with hypertension. Given that many patients who present with epistaxis are hypertensive, these warnings are commonly overridden by clinical necessity. Objectives: To determine the effects of these medications on blood pressure. Methods: We conducted a single-center, randomized, double-blind, placebo-controlled trial from November 2014 through July 2016. Adult patients being discharged from the emergency department (ED) at Mayo Clinic (Rochester, Minnesota) were recruited. Patients were ineligible if they had a contraindication to study medications, had a history of hypertension, were currently taking antihypertensive or antiarrhythmic medications, or had nasal abnormalities such as epistaxis. Subjects were randomized to 1 of 4 study arms (phenylephrine 0.25%; oxymetazoline 0.05%; lidocaine 1% with epinephrine 1:100,000; or bacteriostatic 0.9% sodium chloride [saline]). Blood pressure and heart rate were measured every 5 minutes for 30 minutes. Results: Sixty-eight patients were enrolled in the study; of these, 63 patients completed the study (oxymetazoline, n=15; phenylephrine, n=20; lidocaine with epinephrine, n=11; saline, n=17). We did not observe any significant differences in mean arterial pressure over time between phenylephrine and saline, oxymetazoline and saline, or lidocaine with epinephrine and saline. The mean greatest increases from baseline in mean arterial pressure, systolic and diastolic blood pressure, and heart rate for each treatment group also were not significantly different from the saline group. Conclusion: Intranasal vasoconstrictors did not significantly increase blood pressure in patients without a history of hypertension. Our findings reinforce the practice of administering these medications to patients who present to the ED with epistaxis, regardless of high blood pressure.

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“…Even though clinicians suppose that topical decongestants cause hypertension and reflex bradycardia, there are not many studies supporting this [7]. Similarly, NE may also increase pulse rate and arterial blood pressure [4].…”

Section: Discussionmentioning

confidence: 99%

“…However, the benefits of local anesthetics are controversial, partly because they cause discomfort to patients because of the bad taste and smell [5,6]. Furthermore, there is always a suspicion that local decongestants may cause hypertension and reflex bradycardia [7]. Some authors recommend no medication before NE on the strength of placebo-controlled studies [8-11].…”

Section: Introductionmentioning

confidence: 99%

Premedication Methods in Nasal Endoscopy: A Prospective, Randomized, Double-Blind Study

Şahin¹,

Kökoğlu²,

Güleç³

et al. 2017

Clin Exp Otorhinolaryngol

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ObjectivesTo identify the optimal pharmacological method of preparing patients for nasal endoscopy.Methods Twenty healthy volunteers were enrolled in this prospective, randomized, double-blind study. Four types of medications were applied in their nostrils with binary combinations of spray bottles on four different days in a random order: placebo (normal saline [NS]+NS), decongestant (NS+oxymetazoline), anesthetic (NS+lidocaine), and decongestant plus anesthetic (oxymetazoline+lidocaine). Rigid nasal endoscopy was performed 10 minutes after spray application. The volunteers evaluated the discomfort caused by each spray application, and nasal pain scores due to the passage of the endoscope. The physicians quantified nasal decongestion using a visual analogue scale. Endoscopy duration as well as pulse and mean blood pressure (MBP) before spray application, 10 minutes after the application, and immediately after endoscopic examination were also recorded.Results The discomfort caused by lidocaine was significantly higher than that caused by the other sprays (P<0.001). The lowest pain score related to endoscopy was obtained for oxymetazoline+lidocaine (P<0.001). Nasal decongestion was best achieved with NS+oxymetazoline (P<0.001). Endoscopy duration was the shortest for oxymetazoline+ lidocaine (P<0.05). Statistically significant MBP changes were only seen with the application of NS+oxymetazoline (P<0.05). However, neither MBP nor pulse rate change was significant clinically.Conclusion Application of decongestant and anesthetic sprays together seems to be the best method of pharmacological preparation of patients for nasal endoscopy.

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Oxymetazoline and hypertensive crisis in a child: can we prevent it?

Abstract: Our testing indicates that bottle position during oxymetazoline administration can cause up to a 75-fold increase in intended drug administration.

Cited by 25 publications

References 26 publications

Hemodynamic and pharmacokinetic analysis of oxymetazoline use during nasal surgery in children

Hemodynamic and pharmacokinetic analysis of oxymetazoline use during nasal surgery in children

Effect of Intranasal Vasoconstrictors on Blood Pressure: A Randomized, Double-Blind, Placebo-Controlled Trial

Premedication Methods in Nasal Endoscopy: A Prospective, Randomized, Double-Blind Study

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