Some more on Oxymetazoline (Afrin™)

Myron Yaster MD and John Fiadjoe MD

First, John and I (MY) absolutely do read your responses to the PAADs so keep them coming! When possible we will publish them individually or group them together. With our new executive council we will try to figure out a more formal way to do this…perhaps a weekly or biweekly reader’s response PAAD. What do you think? Myron Yaster MD

The oxymetazoline PAAD sparked a lot of reader responses. Here are some:

From John Fiadjoe

Phenylephrine and Afrin Part Deux tread cautiously

Afrin is commonly used in the operating room and is a relatively safe medication. The previous PAAD discussed dosing of Oxy Metazoline. Some clinicians are known to spray the bottle into the nose or tonsillar surgical bed after tonsillectomy like a fire hydrant SWEEP. However, vasoconstrictors like Afrin can have severe consequences. After a string of deaths in New York state related to topical phenylephrine the state convened a panel to develop guidelines for use. https://pubs.asahq.org/anesthesiology/article/92/3/859/39767/New-York-State-Guidelines-on-the-Topical-Use-of

Here is the pattern they discovered, Application of a potent vasoconstrictor such as phenylephrine or oxymetazoline results in significant hypertension. Baroreceptor mediated bradycardia may not occur because of pretreatment with atropine or glycopyrrolate. The clinician responds by treating the hypertension with a beta blocker commonly labatelol or esmolol. The patient develops pulmonary  edema and cardiac arrest. Alpha stimulation shifts blood into the pulmonary circulation and the increased after load impairs ventricular ejection. Adding a beta blocking drug may result in cardiovascular collapse. Take home message is the hypertension may not need to be treated and if treatment is required use a direct venodilator that does not depress the myocardium. And if you give a beta blocker remember you can reverse it with Glucagon.

comments

From: Diane Gordon

I just love when I read something in PAAD and think “that’s what I thought!“ On a sustainability note, I’ve used a clean 1ml syringe to administer oxymetazoline for years because 1) at least I know how much I’m giving, even if no one knows what that dose means and 2) one bottle will last all day in a dental room!

From Other Readers:

I read the PAAD today and found it very interesting because I had a recent case of phenylephrine toxicity from nasal phenylephrine spray in a 6 year old for a nasal intubation.  After reviewing the literature and phoning some friends, I was very surprised with how unsafe this practice of using topic vasoconstrictors is.  In fact, there was a death in NY of a 4-year-old attributed to topical phenylephrine that was published in Anesthesiology.    

If anyone does take on this topic to investigate, I wanted to lend my case if it would be helpful.  

I had a 5 year old patient become extremely hypertensive and go into fulminant pulmonary edema after the ENT surgeon put Afrin in her nose. No one believed me when I said it was probably due to the Afrin!