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In Response to Hemodynamic and Pharmacokinetic Analysis of Oxymetazoline Use During Nasal Surgery in Children
Author(s) -
Cartabuke Richard S.,
Anderson Brian J.,
Elmaraghy Charles,
Tumin Dmitry,
Tobias Joseph D.
Publication year - 2019
Publication title -
the laryngoscope
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.181
H-Index - 148
eISSN - 1531-4995
pISSN - 0023-852X
DOI - 10.1002/lary.28198
Subject(s) - medicine , anesthesiology , otorhinolaryngology , head and neck surgery , family medicine , anesthesia , surgery
Thank you for your comments regarding our article “Hemodynamic and Pharmacokinetic Analysis of Oxymetazoline Use During Nasal Surgery in Children”. The authors are grateful that you found our study informative, as your work has been the motivation for our interest in this subject. Currently, the United States Food and Drug Administration (FDA) approves oxymetazoline use in patients who are ≥6 years of age. Unfortunately, pharmacokinetic studies that define the appropriate dosing of this medication in children, especially infants and toddlers, are lacking. These data are needed because it appears that oxymetazoline offers some clinical superiority over other agents. Similar to the case reported by Latham and Jardine, we reported significant hemodynamic effects following the placement of oxymetazoline-soaked pledgets into the nasal cavity of a 4-year-old child during a bilateral inferior turbinate reduction. Subsequently, we had additional anecdotal experience with an adolescent who developed hypertension, left ventricular strain, and pulmonary edema following the unrestricted intraoperative administration of oxymetazoline during closed reduction of a nasal fracture. Latham and Jardine demonstrated that when the bottle is inverted, as may occur when a patient is supine on the operating room table, the volume delivered is 15 to 80 times that delivered in the upright position. These results were independently verified by our group. The current study demonstrates that, despite the volumetric increase of oxymetazoline when administered by nasal pledgets, the serum concentration achieved was not excessive. Importantly, it does not lead to significant hemodynamic changes when used as described. Given the concerns outlined above, we agree wholeheartedly with Dr. Latham that some standardized method is needed for the administration of oxymetazoline. This can be accomplished by measuring out a specific volume of the liquid prior to administration and avoiding the use of an inverted over-the-counter bottle for administration. When oxymetazoline-soaked pledgets are used, the total volume of oxymetazoline should be limited and placement should minimize the potential for absorption from nonsurgical areas. Despite the widespread use of oxymetazoline in a variety of clinical settings, the reports of adverse effects remain rare, sporadic, and anecdotal. Although it may be that underreporting of serious adverse events is present, it may also be that these reports demonstrate that the life-threatening hemodynamic effects require a combination of factors to be present, which are yet to be elucidated. Additional research is needed to more clearly define the safe use of oxymetazoline in pediatric patients in various clinical settings.