An 86-year-old woman presented to a dentist complaining of three retained teeth roots. The dentist planned to retract these teeth. The patient had been prescribed amlodipine and aspirin regularly as antihypertension medication. Although her blood pressure was not well controlled, an operation was not contraindicated. Aspirin was discontinued one week before surgery to curb bleeding tendency.\nOn the day of operation, the patient arrived in a treatment room without any premedication. She was monitored using ECG, pulse oximetry, and noninvasive blood pressure measurements. Her initial blood pressure was 160/70 mm Hg. Pulse oximetry and ECG were normal. The dentist injected 108 mg of preservative-free lidocaine without epinephrine (LIDOCAINE HCL Inj, Huons Co., Ltd, Seoul, Korea) into the gingival mucosa. The patient did not complain of any discomfort other than the usual stinging pain during local injection of lidocaine. Five minutes later, surgery started after checking for sensory extinction. During retraction of the three retained teeth, vital signs were stable and surgery was uneventful. Total operation time was 15 minutes. After surgery, the dentist discussed some precautions with the patient and she made her way to the waiting room on foot with her guardian. After three minutes, the guardian came back to the treatment room and reported that the patient was complaining of itching and a sensation of heat. When the medical attendee took the patient to the day care unit, the patient's scalp and peri-auricular area had turned reddish and she complained of itching and was scratching the lesion.\nFour mg of chlorpheniramine, a first-generation alkylamine antihistamine drug, was injected intramuscularly. While under observation, the patient began to sweat profusely and abruptly lost consciousness. The dentist called a medical team, including us anesthesiologists, for help. On arriving, we began to monitor blood pressure, oxygen saturation, and ECG while taking history from the dentist and the guardian. Simultaneously, we rapidly obtained intravenous access and started infusing Hartmann's solution and supplying oxygen via facial mask. The patient did not respond to her name or physical stimulation but her respiratory pattern was normal. Before supplying oxygen, peripheral oxygen saturation was 95%, heart rate was 55 bpm and blood pressure was 49/38 mm Hg. Immediately after checking vital signs, we injected 10 mg of ephedrine while rapidly infusing Hartmann's solution. While assessing the patient, we suspected anaphylaxis caused by lidocaine and prepared epinephrine for resuscitation. Vital signs were again checked and the pulse rate was 96 bpm and blood pressure was 60/45 mm Hg. Ephedrine in two doses of 5 mg and 10 mg was once again injected with fluid therapy. After that, systolic blood pressure was measured in the 70s and the patient regained consciousness. Fortunately, her vital signs normalized without epinephrine administration. Five minutes after recovery, she vomited once.\nWhen we closely checked her medical history and specific findings after she was fully recovered, we found that she had fainted for 30 minutes after dental care at a local clinic eight years ago. At that time, she was discharged without any problems after rehydration in the emergency room of a nearby hospital. In the present case, only preservative-free lidocaine without epinephrine had been used during dental treatment. We suspected that an anaphylactic reaction to lidocaine could have been the cause of the event. After recovering, she felt a desire to defecate and had diarrhea once. An oxygen saturation graph seemed to show large plethysmographic variability. Judging that intravascular volume was depleted or vascular resistance decreased, we administered 500 mL of Hartmann's solution and 500 mL of colloid intravenously. The patient recovered with an oxygen saturation of 98%, a heart rate of 88 bpm, and blood pressure at 118/81 mm Hg and was discharged after a few hours without any complication. We injected 10 mg of dexamethasone intramuscularly and referred her to the allergy department on the same day. We also recommended that she should be admitted to our hospital for close observation. The allergist made a delayed appointment to examine the suspected hypersensitivity to lidocaine under more stringent conditions because we had administered steroids to prevent a recurrent anaphylactic reaction. A few days later, we also recommended several times by follow-up calls that she should undergo examinations such as the skin prick test or specific serum IgE tests as the allergist had suggested. However, the patient refused, and no tests recommended by the allergist were performed.
A 54-year-old female patient, weighing 77 kg, experienced various symptoms such as clouding of consciousness, hearing impairment, and chills during dental treatment for periodontal disease using a local anesthetic. Under the assumption that these adverse effects were attributable to the use of lidocaine, the patient was transferred to the Department of Allergy to determine whether local anesthesia with bupivacaine would be possible.\nThe Department of Allergy performed skin prick and intradermal tests to test for reactivity to bupivacaine, and the patient tested negative in the skin prick test. In the skin provocation test, when administered an intradermal injection of 0.1 cc bupivacaine diluted to 1:100, the patient complained of listlessness and drowsiness beginning 30 s after the injection. Following an intradermal injection of 0.1 cc bupivacaine diluted to 1:10, the patient's symptoms of listlessness and drowsiness became more severe from 30 s after the injection. When administered an intradermal injection of 0.1 cc of undiluted bupivacaine, the patient was placed in a recumbent position on a bed owing to complaints of listlessness and heavy eyes at approximately 50 s after the injection. Subsequently, the patient showed symptoms of shivering, which eventually became uncontrollable, and she had difficulty keeping her eyes open. As a result, the patient was given 2 doses of 0.5 mg Ativan. Afterward, the patient appeared to be more stable, but began showing symptoms of shaking her chin and one of her arms, for which 0.5 ampule of Demerol™ was administered, after which her condition began to improve. The testing was completed within 20 min and the patient was discharged after a 5 h observation period. The patient was diagnosed with bupivacaine intolerance, meaning the appearance of adverse effects even with small amounts of the medication, and the dental treatment was subsequently performed under general anesthesia since local anesthesia was determined to be impossible.