Safe and Deliberate Use of Oxymetazoline in the Pediatric Operating Room

TO THE EDITOR

Oxymetazoline is a topical vasoconstrictor commonly administered in the operating room intranasally prior to nasotracheal intubation to reduce the risk of bleeding and enhance airway visualization.¹ While used primarily for its local vasoconstrictive effect, excessive administration may result in systemic hemodynamic consequences, particularly hypertension and/or bradycardia.² These effects can be problematic for patients with cardiac and vascular co-morbidities. Concerns for systemic effects due to overdosage are valid, particularly if the medication is administered in a manner inconsistent with the mechanism for delivery designed by the manufacturer. This issue is relevant to anesthesia practice as the delivery system is designed to be used when the bottle and patient are both in the upright position. However, when used to facilitate nasotracheal intubation in the pediatric patient, oxymetazoline is typically administered to asleep and supine patients by inverting the bottle.

Commonly manufactured oxymetazoline bottles employ an integrated pump system intended to deliver a mist into the nare. Some designs have just a small orifice to control the dose whereas other designs connect the administration tip to the medication supply using a straw extending to the base of the bottle (Figure 1). In either case, when the bottle is squeezed in the upright position, 1 spray is intended to dispense approximately 0.03ml of oxymetazoline.¹ However, when the bottle is inverted, medication delivery can be unpredictable. Bottles with an integrated straw may deliver a reduced dose in the inverted position as the straw entrains less medication. However, bottles fit with just a small orifice at the tip can freely drip when inverted and deliver doses of 1ml or more (Supplemental Video 1). Since the intended dose to be administered is 0.03 ml, the use of the bottle in the inverted position can lead to doses much greater than intended. Thus, inverting the bottle and squeezing it into the nose can lead to an unseen large volume overdose with the potential for undesired systemic effects, especially in pediatric patients.

Figure 1: Oxymetazoline spray bottles with integrated pump delivery and manual mist systems.

Oxymetazoline plays an important role in patient care and is safe when dosed properly in the upright position.³ When administering oxymetazoline to a supine pediatric patient, we suggest using an atomizer fitted to a 1 ml syringe (Figure 2). To obtain the medication, the bottle can be opened to remove a specific dose of medication using a syringe (Figure 3). Syringe administration ensures a controlled dose is administered reducing the risk of undesired systemic effects.

Figure 2: Use of a 1 mL syringe fitted with disposable atomizer.

Figure 3: Spray bottle with top removed allowing access for withdrawal of mediation.

In summary, oxymetazoline is commonly used in pediatric surgical patients. The perioperative care team should ensure deliberate administration whenever oxymetazoline is used in the operating room to avoid accidental over-administration.

Robert Vernick, BS is a medical student at Campbell University School of Osteopathic Medicine, Lillington, North Carolina, USA

Dr. Arvind Chandrakantan is an Associate Professor of Anesthesiology at Baylor College of Medicine, Houston, Texas, USA and staff Anesthesiologist at Texas Children’s Hospital, Houston Texas, USA

Dr. Adam Adler is an Associate Professor of Anesthesiology at Baylor College of Medicine, Houston, Texas, USA and staff Anesthesiologist at Texas Children’s Hospital, Houston Texas, USA

The authors have no conflicts of interest.

REFERENCES

1. Cartabuke R, Tobias JD, Jatana KR; Section on Anesthesiology and Pain Medicine, Section on Otolaryngology – Head and Neck Surgery. Topical Nasal Decongestant Oxymetazoline: Safety Considerations for Perioperative Pediatric Use. Pediatrics 2021;148(5).
2. Latham GJ, Jardine DS. Oxymetazoline and hypertensive crisis in a child: can we prevent it? Paediatr Anaesth 2013;23(10):952-6.
3. Cartabuke RS, Anderson BJ, Elmaraghy C, Rice J, Tumin D, Tobias JD. Hemodynamic and pharmacokinetic analysis of oxymetazoline use during nasal surgery in children. Laryngoscope 2019;129(12):2775-2781.