Thank you for your inquiry.
Normally, at least in my practice, one chooses a local anesthetic to which the patient has not reacted if possible. Part of the reasoning behind this is that it tends to increase the patient’s confidence that they will be able to tolerate the drug. On occasion, anxiety related to the testing procedure, can cause problems during the procedure, and anything one can do to mollify this is indicated. Therefore, in your case, I would recommend bupivacaine since you have said that it is an acceptable option. The testing/graded dosage challenge procedure is the same for all local anesthetics.
I would do this even though true allergic reactions to amide anesthetics are extremely rare. This brings up a parenthetic point which would not affect my choice of local anesthetics, but I mention only for the sake of interest.
As mentioned, true allergic reactions to amide local anesthetics such as lidocaine are extremely rare, whereas they are far more common to paraaminobenzoic acid preparations such as benzocaine. It is curious to note that, if one goes online, one can find Solarcaine products listed as containing benzocaine. For your interest, I have copied below a link to two of these websites (there are several). I assume it is feasible that the reaction your patient described could have been to one of these benzocaine-containing products if they were available to the family. This would of course make the whole issue a “straw man.”
Regardless, in the vast majority of instances, as I am sure you are aware, alternative amide local anesthetic agents can be safely tested and administered using the testing/graded dosage regimen you mentioned. I would not anticipate any problem with the bupivacaine.
Thank you again for your inquiry and we hope this response is helpful to you.
Phil Lieberman, M.D.