Lesson of the Week: Cocaine and adrenaline paste: a fatal combination?

doi:10.1136/bmj.311.6999.250

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K E A Nicholson, senior registera,
J E G Rogersb

^aDepartment of Anaesthesia, Norfolk and Norwich Hospital, Norwich NR1 3SR
^bDepartment of Anaesthesia, Addenbrooke's Hospital, Cambridge CB2 2QQ

bCorrespondence to: Dr J E G Rogers

Accepted 1 November 1994

Cocaine and adrenaline paste is most commonly used by otorhinolaryngologists for operations on the nose, including rhinoplasty and submucous resection. Cocaine readily penetrates mucous membranes and is an effective topical anaesthetic with an intense vasoconstrictor action that facilitates surgery and improves haemostasis. Cocaine blocks the reuptake of noradrenaline at sympathetic nerve terminals, thus potentiating sympathetic activity. Although local vasoconstriction is produced, arrhythmias and hypertension may occur.1 Adrenaline is used in combination with cocaine to intensify the vasoconstrictor effect, thus improving the operative field, and also to reduce absorption of cocaine into the systemic circulation. Interaction between cocaine and adrenaline, however, may increase circulating concentrations of catecholamines and lead to arrhythmias.

Case reports

CASE 1

A fit 9 year old girl weighing 28 kg presented for examination of her nose under anaesthesia. She was given premedication with oral atropine. Anaesthesia was induced with thiopentone, and tracheal intubation was facilitated with suxamethonium. Anaesthesia was maintained with oxygen in nitrous oxide 66% and halothane 1%, and ventilation was assisted. Five minutes into the operation about 0.5 ml of paste containing cocaine 25% and adrenaline 0.18% (125 mg cocaine and 0.9 mg adrenaline) was placed in her nose. Instruments were immediately passed up the nose and within 10 …