Methemoglobinemia in the Operating Room and Intensive Care Unit: Early Recognition, Pathophysiology, and Management
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REVIEW
Methemoglobinemia in the Operating Room and Intensive Care Unit: Early Recognition, Pathophysiology, and Management John N. Cefalu . Tejas V. Joshi . Matthew J. Spalitta . Carson J. Kadi . James H. Diaz . Jonathan P. Eskander . Elyse M. Cornett . Alan D. Kaye
Received: March 28, 2019 Ó The Author(s) 2020
ABSTRACT The objectives of this review are to describe the acquired and hereditary causes of methemoglobinemia, to recommend the most sensitive diagnostic tests, and to enable critical care clinicians to rapidly detect and treat methemoglobinemia. To meet these objectives, Internet search engines were queried with the
Enhanced Digital Features To view enhanced digital features for this article go to https://doi.org/10.6084/ m9.figshare.11907084. J. N. Cefalu T. V. Joshi M. J. Spalitta C. J. Kadi J. H. Diaz A. D. Kaye (&) Department of Anesthesiology, Louisiana State University Health Sciences Center, Room 656, 1542 Tulane Avenue, New Orleans, LA 70112, USA e-mail: [email protected] J. H. Diaz Department of Public Health, Louisiana State University Health Sciences Center, 1542 Tulane Avenue, New Orleans, LA 70112, USA J. P. Eskander Department of Anesthesiology, Portsmouth Anesthesia Associates, 3200 Tyre Neck Rd Suite 101, Portsmouth, VA 23703, USA E. M. Cornett Department of Anesthesiology, Louisiana State University Health Sciences Center Shreveport, 1501 Kings Highway, Shreveport, LA 71103, USA
keywords to select articles for review that included case reports, case series, observational, longitudinal, and surveillance studies. The most common causes of methemoglobinemia include oxidizing reactions to cocaine-derived anesthetics, such as benzocaine and lidocaine, to antibiotics, such as dapsone and other sulfonamides, and to gases, such as nitric oxide. Additionally, CO-oximetry is superior to standard pulse oximetry in detecting methemoglobinemia. Finally, effective treatments for methemoglobinemia include intravenous administration of methylene blue, ascorbic acid, and riboflavin. In this manuscript we will discuss methemoglobinemia, how it occurs, and how to treat it.
Keywords: Ascorbic acid; Benzocaine; Dapsone; Hyperbaric oxygen; Lidocaine; Methemoglobinemia; Methylene blue; Nitric oxide; Pain; Riboflavin
Adv Ther
INTRODUCTION Key Summary Points Methemoglobinemia can present as a challenge for clinicians to both diagnose and treat in the intensive care unit and the operating room. Clinically, methemoglobinemia may manifest as dyspnea, nausea, cyanosis, and tachycardia to much more extreme symptoms such as lethargy, stupor, and deteriorating consciousness. Methemoglobinemia can be diagnosed by a discrepancy between the SpO2 and SaO2 that is refractory to oxygen therapy, signs of cyanosis, decreased SpO2 hovering at 85%, chocolate-colored blood, acidosis and tachycardia, and most effectively with use of CO-oximetry. The most common drugs that cause methemoglobinemia include cocainederived anesthetics such as benzocaine and lidocaine, antibiotics such as dapsone, and gases such as
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