Warning! Exactacain Straw Must Fit Spray Release Button

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Warning! Exactacain straw must fit spray release button. Some facilities are using EXACTACAIN Spray (benzocaine 14%, butamben 2%, tetracaine 2%) to numb patients’ throats before endoscopy procedures. The metered-dose product is packaged with disposable applicator straws for each patient to help control the dose of spray, and it has a lower benzocaine dose than some competitors–factors that may reduce the risk of methemoglobinemia. However, there is a temporary safety risk with the product. A hospital pharmacist recently received a call from a nurse in the endoscopy suite, complaining that the tiny applicator straws were “popping off into patients’ throats” during release of the spray. The nurse stated that “the old red straws don’t do this, but the new clear ones do.” As a temporary fix, one of the pharmacists found some old red straws and gave them to her. He then called the manufacturer, Healthpoint, and learned that, about a year ago, it changed the spray release button (the white button on the container that you push down), which necessitated resizing the applicator straws that attach to it. Since the company ships the straws and the bottles as a kit, they assumed that practitioners would use the correct straws. But with boxes of both the old red and new clear straws available, nurses were sometimes trying to use an old straw with a new container, and a new straw with an old container.

Figure 1. Red straw should be used with
older Exactacain containers. Clear straws will
pop out if used with the older containers.

The old straws do not fit tightly with the new container, and vice versa, thus, the difficulty with straws popping into patient’s throats. Since spraying a patient’s oropharyngeal mucosa with Exactacain takes away the gag reflex, this is a potentially dangerous situation. An anesthesia group at a different location also reported the same problem to us. If you use Exactacain, only the straws that come with the bottle should be used. Discard leftover straws when starting a new bottle. Be sure to press the straws firmly into the hole on the spray applicator. The usual dose is 3 sprays; more than 6 should never be administered. That’s unrelated to this issue but a good refresher in light of past problems with methemoglobinemia (Moore TJ, Walsh CS, Cohen MR. Reported adverse event cases of methemoglobinemia associated with benzocaine products. Arch Intern Med2004;164: 1192-1196; also visit www.ismp.org/newsletters/acutecare/articles/20021003.asp for information).