Topical Phenylephrine Risks

 

       Otolaryngologists commonly use topical vasoconstrictors to control bleeding from nasal and pharyngeal surgical sites.[1] However, topical vasoconstrictors applied to a surgical field can be absorbed into the blood stream and may result in significant cardiovascular side effects and even death.[2-4] A review of several mortality cases involving topical phenylephrine found that death may have been related to over-aggressive treatment of hypertensive side effects with beta-blockers, resulting in worsening systemic vasoconstriction due to unopposed alpha-adrenergic effect.[2]

 

       Due to these concerns the State of New York created a Phenylephrine Advisory Committee to develop and publish guidelines regarding the use of topical phenylephrine.  The rational supporting these guidelines was published in Anesthesiology in March 2000.[2] The following is a summary of their guidelines that may be helpful in practice:

 

  1. The initial dose of phenylephrine for adults should not exceed 0.5 mg (four drops of 0.25% solution.)  In children (up to 25 kg), the initial dose should not exceed 20 ug/kg.
  2. The minimal amount of phenylephrine needed to achieve vasoconstriction should be administered.  Blood pressure and pulse should be closely monitored after phenylephrine is given.
  3. The dose of phenylephrine should be administered in a calibrated syringe and should be verified by a physician.
  4. The anesthesiologist involved in the case should be aware of all medications that are administered to the patient.
  5. Mild-to-moderate hypertension resulting from phenylephrine use should be closely monitored for 0-15 minutes before antihypertensive medications are given.  Severe hypertension, as well as adverse effects such as ECG changes or pulmonary edema, should be treated immediately.  Antihypertensive agents that are direct vasodilators or alpha-receptor antagonists (such as phentolamine) are appropriate treatments.
  6. The use of beta-blockers and calcium channel blockers should be avoided when vasoconstrictive agents such as phenylephrine are used. The medical literature suggests that the use of beta-blockers and calcium channel blockers as treatment of hypertension secondary to a vasoconstrictor may result in an unopposed alpha effect leading to worsened cardiac output and pulmonary edema.
  7. If a beta-blocker is inadvertently used for the treatment of hypertension, glucagon may be considered to counteract the loss of cardiac contractility.

 

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References:

1.             Riegle, E.V., et al., Comparison of vasoconstrictors for functional endoscopic sinus surgery in children. Laryngoscope, 1992. 102(7): p. 820-3.

2.                Groudine, S.B., et al., New York State guidelines on the topical use of phenylephrine in the operating room. The Phenylephrine Advisory Committee. Anesthesiology, 2000. 92(3): p. 859-64.

3.             Greher, M., et al., Hypertension and pulmonary edema associated with subconjunctival phenylephrine in a 2-month-old child during cataract extraction. Anesthesiology, 1998. 88(5): p. 1394-6.

4.                Kalyanaraman, M., et al., Cardiopulmonary compromise after use of topical and submucosal alpha- agonists: possible added complication by the use of beta-blocker therapy. Otolaryngol Head Neck Surg, 1997. 117(1): p. 56-61.