The efficacy of lidocaine to prevent laryngospasm in children: a systematic review and meta-analysis

Negative pressure pulmonary edema (Review)

Negative pressure pulmonary edema (NPPE) is a complication resulting from acute or chronic upper airway obstruction, often posing challenges in recognition and diagnosis for clinicians. If left untreated, NPPE can lead to hypoxemia, heart failure and even shock. Furthermore, the drug treatment of NPPE remains a subject of controversy. The primary pathophysiological mechanism of NPPE involves the need for high inspiratory pressure to counteract upper airway obstruction, subsequently causing a progressive rise in negative pressure within the pleural cavity. Consequently, this results in increased pulmonary microvascular pressure, leading to the infiltration of pulmonary capillary fluid into the alveoli. NPPE exhibits numerous risk factors and causes, with laryngospasm following anesthesia and extubation being the most prevalent. The diagnosis of NPPE often presents challenges due to confusion with conditions such as gastroesophageal reflux or cardiogenic pulmonary edema, given the similarity in initial factors triggering both diseases. Upper airway patency, positive pressure non-invasive ventilation, supplemental oxygen and re-intubation mechanical ventilation are the foundation of the treatment of NPPE. The present review aims to discuss the etiology, clinical presentation, pathophysiology and management of NPPE.

Comparison of intravenous injection of magnesium sulfate and lidocaine effectiveness on the prevention of laryngospasm and analgesic requirement in tonsillectomy

The aim of the present study is to compare the effect of intravenous (IV)injectionof magnesium sulfate and lidocaine on the prevention of laryngospasm, and analgesic requirement in tonsillectomy surgeries. In this double-blinded clinical trial, 62 children are randomly selected and categorized into two groups. Two minutes after intubation, group A received 15 mg/kg IV magnesium sulfate, while group B received 1 mg/kg IV 2% lidocaine. Laryngospasm frequency, nausea and vomiting, hemodynamic status (in 15 minutes after extubating), sedation score, analgesic requirement, and duration of recovery were compared between the two groups. Data were analyzed using SPSS software version 21 and with a 95% confidence interval. Both groups had no significant difference based on the age and weight means, as well as sex frequency. 10 patients (32.3%) in the lidocaine group and 3 patients in the magnesium group (9.7%) had stridor, and the difference between the two groups was statistically significant (p = 0.026). Laryngospasm only occurred in a patient of the lidocaine group. The frequency of nausea and vomiting, agitation and analgesic requirement in the lidocaine group were higher than the magnesium group (p= 0.001). However, sedation score and recovery time were higher in the magnesium group (p=0.001). No statistically significant difference was seen between the two groups in terms of hemodynamics. Magnesium sulfate and lidocaine had no difference in the incidence of laryngospasm, but magnesium sulfate was associated with a lower rate of stridor, nausea, vomiting, agitation and analgesic requirement in recovery in comparison to lidocaine.

Endoscopic aspects and associated factors in paradoxical vocal fold movement

INTRODUCTION

Paradoxical vocal fold movement (PVFM) is a respiratory disorder related to inadequate movement of vocal folds during inspiration or expiration. Its epidemiology and pathogenesis are unknown. The present study describes the standardization of the examination performed in our service and the main endoscopic changes found, evaluating the prevalence of PVFM in patients with suggestive symptoms and describing the association of PVFM with asthma and other diseases.

MATERIALS AND METHODS

Retrospective observational study of a series of cases over a 13-year period - adult patients referred for outpatient bronchoscopy due to suspected PVFM.

RESULTS

We analyzed 1131 laryngoscopies performed on patients referred for suspicion of PVFM from May 2006 to June 2019. Of these, 368 cases were excluded from the study. A total of 255 patients (33%) had a confirmed diagnosis of PVFM, 224 women (88%). The most frequent comorbidities found were asthma (62%), rhinitis (45%), gastro-oesophageal reflux disease (45%), obesity (24%), and psychiatric disorders (19%). Among the endoscopic findings concomitant with the diagnosis of PVDM, we highlight posterior laryngitis (71%), diseases of the nasal septum (18%), nasal polyps (7%).

DISCUSSION

Female sex is more affected. There are several associations with other diseases, the main one being asthma, followed by rhinitis and psychiatric disorders. Obesity appears as a comorbidity in 24% of patients, as does sleep apnoea in 13%. Posterior laryngitis was the most common endoscopic finding. PVFM is an underdiagnosed disease, little known as it is a rare entity that still needs prospective studies. Exam standardization is important.

Propofol versus lidocaine on prevention of laryngospasm in tonsillectomy: A randomized clinical trial

Laryngospasm is an important complication of tonsillectomies. This study aimed to compare the effects of propofol versus lidocaine on prevention of laryngospasm in tonsillectomy. This randomized clinical trial included 102 patients who met the inclusion criteria. Patients were randomly divided into two groups treated with 0.5 mg/kg propofol (group P) or 1 mg/kg lidocaine 2% (group L). The frequencies of laryngospasm (within 10 min after extubation), agitation, nausea, vomiting, mean heart rate and mean arterial pressure (MAP) were assessed in both groups. Data were analyzed using SPSS software version 16 at a 95% confidence level. There were no significant differences between the two groups in terms of sex, age or weight. In the P group, the frequency of laryngospasm was significantly lower than L within10 minutes after extubation (4.1% versus 16.3%). Furthermore, the frequencies of agitation (p = 0.003), nausea and vomiting (p = 0.002) and mean heart rate (p = 0.026) were significantly higher in the L group than the P group. However, there were no differences between the two groups in terms of mean systolic and diastolic blood pressure, MAP, SPO2, awakening time, length of stay in recovery and frequency of shivering. Propofol can reduce the incidence of laryngospasm, agitation, nausea and vomiting but it has no effect on the patient's awakening time and length of stay in recovery.

Anesthetic considerations in children with asthma

Due to the high prevalence of asthma and general airway reactivity, anesthesiologists frequently encounter children with asthma or asthma-like symptoms. This review focuses on the epidemiology, the underlying pathophysiology, and perioperative management of children with airway reactivity, including controlled and uncontrolled asthma. It spans from preoperative optimization to optimized intraoperative management, airway management, and ventilation strategies. There are three leading causes for bronchospasm (1) mechanical (eg, airway manipulation), (2) non-immunological anaphylaxis (anaphylactoid reaction), and (3) immunological anaphylaxis. Children with increased airway reactivity may benefit from a premedication with beta-2 agonists, non-invasive airway management, and deep removal of airway devices. While desflurane should be avoided in pediatric anesthesia due to an increased risk of bronchospasm, other volatile agents are potent bronchodilators. Propofol is superior in blunting airway reflexes and, therefore, well suited for anesthesia induction in children with increased airway reactivity.

Impact of topical airway anesthesia on immediate postoperative cough/bucking: a systematic review and meta-analysis

BACKGROUND

Postoperative cough may occur after tracheal intubation, but it is indistinct which drug is best at diminishing these events. Additionally, airway reflexes are commonly accompanied by severe hemodynamics responses during emergence.

OBJECTIVES

To evaluate the role of topical airway anesthesia on immediate post-extubation cough/bucking and extubation time.

METHODS

Randomized clinical trials from MEDLINE, EMBASE, CENTRAL, and LILACS published until December 23, 2020 were included. Our primary outcome was postoperative cough/bucking incidence which was compared between local anesthetics and controls. Extubation times were likewise considered. Predisposition appraisal and subgroup, affectability investigations were likewise performed.

RESULTS

The pooled analysis found a 45% reduction in cough incidence after treatment with topical airway local anesthetic (RR.á=.á0.55; 95% CI: 0.42 to 0.72; p.á<.á0.001). The number needed to treat (NNT) was 4.61. The intervention showed no differences in reduction of the extubation time (mean difference = -0.07; 95% CI: -0.14 to 0.28; p.á=.á0.49).

CONCLUSION

Topical airway anesthesia demonstrated better than placebo or no medication in reducing immediate post-extubation cough/bucking. Further studies could have this objective to combine the different ways to perform better outcomes for patients.

Negative Pressure Pulmonary Edema Related to Laryngospasm and Upper Airway Obstruction in a Patient With Treacher Collins Syndrome

Laryngospasm is an uncommon complication of anesthesia in adults but more common in pediatric anesthesia, which could present similarly to supraglottic upper airway obstruction. The management of such airway complications is even more difficult in patients with difficult mask ventilation and intubation. Our case illustrated the management of laryngospasm and negative pressure pulmonary edema in a patient with Treacher Collins syndrome. A literature search revealed few previous similar reports. We demonstrated an algorithm to differentiate between the true laryngospasm from the supraglottic upper airway obstruction, the management of laryngospasm in patients with difficult airways, and the recognition and management of negative pressure pulmonary edema as a complication of laryngospasm.

The impact of topical lidocaine and timing of LMA removal on the incidence of airway events during the recovery period in children: a randomized controlled trial

Background

The timing of laryngeal mask airway (LMA) removal remains undefined. This study aimed to assess the optimal timing for LMA removal and whether topical anesthesia with lidocaine could reduce airway adverse events.

Methods

This randomized controlled trial assessed one-to-six-year-old children with ASA I-II scheduled for squint correction surgery under general anesthesia. The children were randomized into the LA (lidocaine cream smeared to the cuff of the LMA before insertion, with mask removal in the awake state), LD (lidocaine application and LMA removal under deep anesthesia), NLA (hydrosoluble lubricant application and LMA removal in the awake state) and NLD (hydrosoluble lubricant application and LMA removal in deep anesthesia) groups. The primary endpoint was a composite of irritating cough, laryngeal spasm, SpO₂ < 96%, and glossocoma in the recovery period in the PACU. The secondary endpoints included the incidence of pharyngalgia and hoarseness within 24 h after the operation, duration of PACU stay, and incidence of agitation in the recovery period. The assessor was unblinded.

Results

Each group included 98 children. The overall incidence of adverse airway events was significantly lower in the LA group (9.4%) compared with the LD (23.7%), NLA (32.6%), and NLD (28.7%) groups (P=0.001). Cough and laryngeal spasm rates were significantly higher in the NLA group (20.0 and 9.5%, respectively) than the LA (5.2 and 0%, respectively), LD (4.1 and 1.0%, respectively), and NLD (9.6 and 2.1%, respectively) groups (P=0.001). Glossocoma incidence was significantly lower in the LA and NLA groups (0%) than in the LD (19.6%) and NLD (20.2%) groups (P< 0.001). At 24 h post-operation, pharyngalgia incidence was significantly higher in the NLA group (15.8%) than the LA (3.1%), LD (1.0%), and NLD (3.2%) groups (P< 0.001).

Conclusions

LMA removal in the awake state after topical lidocaine anesthesia reduces the incidence of postoperative airway events.

Trial registration

ChiCTR, ChiCTR-IPR-17012347. Registered August 12, 2017.

Laryngeal reflex responses in pediatric anesthesia

Laryngeal and respiratory reflexes are vitally important defense mechanisms against foreign body aspiration, safeguarding airway patency, and ventilation. These highly preserved automatisms easily overrule external influences like willpower or (anesthetic) medication. Prevention and anticipation are, therefore, the essential strategies to avoid adverse events and damage, and treatment is most effective in the early stage of the reflex response. The physiology and pathophysiology of the various defensive reflexes as well as a comprehensive anesthetic approach to prevention and treatment are outlined in this review.

Effectiveness of intravenous lidocaine in preventing postoperative nausea and vomiting in pediatric patients: A systematic review and meta-analysis

BACKGROUND

Intravenous lidocaine in adults undergoing general anesthesia has been shown to reduce the incidence of postoperative nausea and vomiting (PONV). However, the anti-postoperative vomiting (POV) effect of lidocaine in pediatric patients remains unclear. We conducted a systematic review and meta-analysis with Trial Sequential Analysis to evaluate the effect of intravenous lidocaine on prevention of POV/PONV.

METHODS

Six databases including trial registration sites were searched. Randomized clinical trials evaluating the incidence of POV/PONV after intravenous lidocaine compared with control were included. The primary outcome was the incidence of POV within 24 hours after general anesthesia. The incidence of POV was combined as a risk ratio with 95% confidence interval using a random-effect model. We used the I2 to assess heterogeneity. We evaluated the quality of trials using the Cochrane methodology, and we assessed quality of evidence using the Grading of Recommendation Assessment, Development, and Evaluation approach. We also assessed adverse events.

RESULTS AND DISCUSSION

Six trials with 849 patients were included, of whom 433 received intravenous lidocaine. Three trials evaluated the incidence of POV, and 3 evaluated the incidence of PONV. The overall incidence of POV within 24 hours after anesthesia was 45.9% in the lidocaine group and 63.4% in the control group (risk ratio, 0.73; 95% confidence interval, 0.53-1.00; I2 = 32%; p = 0.05). The incidence of PONV within 24 hours after anesthesia was 3.73% in the lidocaine group and 4.87% in the control group (RR, 0.76; 95% CI, 0.36-1.59; I2 = 0%; p = 0.47). The quality of evidence was downgraded to "very low" due to the study designs, inconsistency, imprecision, and possible publication bias.

CONCLUSION

Our meta-analysis suggests that intravenous lidocaine infusion may reduce the incidence of POV, however, the evidence quality was "very low." Further trials with a low risk of bias are necessary.

Management of Refractory Laryngospasm

Laryngospasm has been well described in patients emerging from general anesthesia (GA) and is routinely managed with intermittent positive-pressure mask ventilation, a temporary increase in the depth of anesthesia, or small, titrated amounts of succinylcholine. Patients with severe laryngospasm require reintubation to maintain adequate oxygenation and ventilation. However, reintubation may be only a temporary solution because laryngospasm may recur during re-emergence and re-extubation; thus, anesthesiologists need a comprehensive plan that addresses potential causes of laryngospasm and incorporates continuous positive airway pressure (CPAP) for patients with difficulty emerging from GA. Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) is a noninvasive ventilation and oxygenation technique used to provide apneic oxygenation, which also generates CPAP. THRIVE uses a high-flow nasal cannula and is more easily tolerated than CPAP with a tight-fitting mask. To our knowledge, we present the first case of refractory laryngospasm during emergence from GA that was successfully managed with THRIVE.

Prophylactic Effects of Intravenous Dexamethasone and Lidocaine on Attenuating Hemodynamic-Respiratory and Pain Complications in Children Undergoing Cleft Palate Repair Surgery With General Anesthesia

This study aimed to compare the prophylactic effects of intravenous (IV) dexamethasone and lidocaine on hemodynamic condition, respiratory complications, pain control, and vomit incidence following cleft palate repair surgery. This double-blind randomized controlled trial was carried out on 87 children assigned to three groups. Prior to anesthesia, subjects in groups D and L received 0.2 and 1 mg/kg IV dexamethasone and lidocaine, respectively. Moreover, group C received placebo in a similar condition. The outcome variables were recorded prior to the surgery and then every 15 minutes during the surgical and recovery time. Mean heart rate (HR), mean arterial blood pressure (MABP), and mean end-tidal carbon dioxide (ETCO2) during the surgical time were not significantly different between dexamethasone and lidocaine groups. Dexamethasone significantly improved the level of blood oxygen saturation (SPO2) during the recovery time. Nevertheless, MABP in recovery time did not significantly decrease in the dexamethasone group. There were no significant differences in respiratory complications, pain score, and vomiting incidence between lidocaine and dexamethasone groups. Premedication with both IV dexamethasone and lidocaine provided similar stable hemodynamic and respiratory conditions during the surgical time. However, the use of dexamethasone developed more desirable effects on HR and SPO2 than administration of lidocaine during the recovery time. Both drugs significantly lessened postoperative pain compared to the placebo group at this time.

Nebulized Lidocaine in the Treatment of Refractory Postoperative Laryngospasm: A Case Report

Intraoperative laryngospasm occurs in <1% of cases. Recurrent laryngospasm is rarer. Some risk factors include shared airway and pediatric surgery, secretions, pungent volatile anesthetics, and patient factors, such as smoking and asthma. Conventional management includes the application of positive airway pressure, jaw thrust, the removal of any offending stimuli, deepening anesthesia, or administering muscle relaxants. Nebulized lidocaine is used to anesthetize the vocal cords before awake fiberoptic intubation. This case highlights the novel use of nebulized lidocaine to successfully treat refractory postoperative laryngospasm in a fully conscious adult patient after conventional measures were unsuccessful.

Muscles of Breathing: Development, Function, and Patterns of Activation

This review is a comprehensive description of all muscles that assist lung inflation or deflation in any way. The developmental origin, anatomical orientation, mechanical action, innervation, and pattern of activation are described for each respiratory muscle fulfilling this broad definition. In addition, the circumstances in which each muscle is called upon to assist ventilation are discussed. The number of "respiratory" muscles is large, and the coordination of respiratory muscles with "nonrespiratory" muscles and in nonrespiratory activities is complex-commensurate with the diversity of activities that humans pursue, including sleep (8.27). The capacity for speech and adoption of the bipedal posture in human evolution has resulted in patterns of respiratory muscle activation that differ significantly from most other animals. A disproportionate number of respiratory muscles affect the nose, mouth, pharynx, and larynx, reflecting the vital importance of coordinated muscle activity to control upper airway patency during both wakefulness and sleep. The upright posture has freed the hands from locomotor functions, but the evolutionary history and ontogeny of forelimb muscles pervades the patterns of activation and the forces generated by these muscles during breathing. The distinction between respiratory and nonrespiratory muscles is artificial, as many "nonrespiratory" muscles can augment breathing under conditions of high ventilator demand. Understanding the ontogeny, innervation, activation patterns, and functions of respiratory muscles is clinically useful, particularly in sleep medicine. Detailed explorations of how the nervous system controls the multiple muscles required for successful completion of respiratory behaviors will continue to be a fruitful area of investigation. © 2019 American Physiological Society. Compr Physiol 9:1025-1080, 2019.

Manejo perioperatorio de niños con infección respiratoria superior

Introducción. Es frecuente que muchos niños sometidos a procedimientos con anestesia general tengan historia de infección viral respiratoria superior reciente o activa.Objetivo. Realizar una revisión narrativa acerca de las pautas de manejo anestésico para los niños con infección reciente o activa de la vía aérea superior.Materiales y métodos. Se realizó una búsqueda estructurada de la literatura en las bases de datos ProQuest, EBSCO, ScienceDirect, PubMed, LILACS, Embase, Trip Database, SciELO y Cochrane Library con los términos Anesthesia AND Respiratory Tract Infections AND Complications; Anesthesia AND Upper respiratory tract infection AND Complications; Anesthesia, General AND Respiratory Tract Infections AND Complications; Anesthesia, General AND Upper respiratory tract infection AND Complications; Anesthesia AND Laryngospasm OR Bronchospasm. La búsqueda se hizo en inglés con sus equivalentes en español.Resultados. Se encontraron 56 artículos con información relevante para el desarrollo de la presente revisión.Conclusiones. Una menor manipulación de la vía aérea tiende a disminuir la frecuencia de aparición y severidad de eventos adversos respiratorios perioperatorios. No existe evidencia suficiente para recomendar la optimización medicamentosa en pacientes con infección respiratoria superior.

Management of the child's airway under anaesthesia: The French guidelines

OBJECTIVE

To provide French guidelines about "Airway management during paediatric anaesthesia".

DESIGN

A consensus committee of 17 experts from the French Society of Anaesthesia and Intensive Care Medicine (Société Française d'Anesthésie-Réanimation, SFAR) and the Association of French speaking paediatric anaesthesiologists and intensivists (Association Des Anesthésistes Réanimateurs Pédiatriques d'Expression Francophone, ADARPEF) was convened. The entire process was conducted independently of any industry funding. The authors followed the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to assess the quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. Few recommendations were not graded.

METHODS

The panel focused on 7 questions: 1) Supraglottic Airway devices 2) Cuffed endotracheal tubes 3) Videolaryngoscopes 4) Neuromuscular blocking agents 5) Rapid sequence induction 6) Airway device removal 7) Airway management in the child with recent or ongoing upper respiratory tract infection. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. The analysis of the literature and the redaction of the recommendations were then conducted according to the GRADE® methodology.

RESULTS

The SFAR Guideline panel provides 17 statements on "airway management during paediatric anaesthesia". After two rounds of discussion and various amendments, a strong agreement was reached for 100% of the recommendations. Of these recommendations, 6 have a high level of evidence (Grade 1 ± ), 6 have a low level of evidence (Grade 2 ± ) and 5 are experts' opinions. No recommendation could be provided for 3 questions.

CONCLUSIONS

Substantial agreement exists among experts regarding many strong recommendations for paediatric airway management.

Topical Pharyngeal Lidocaine Reduces Respiratory Adverse Events During Upper Gastrointestinal Endoscopies Under Ketamine Sedation in Children

BACKGROUND

Upper gastrointestinal endoscopies (UGEs) performed under ketamine sedation may increase the risk of respiratory adverse events (RAEs) due to pharyngeal stimulation. Topical lidocaine prevents general anesthesia-induced laryngospasm.

OBJECTIVE

Our objective was to determine whether topical lidocaine may reduce the incidence of RAEs induced by pharyngeal stimulation in UGEs performed on children sedated with ketamine.

METHODS

We conducted a single-center prospective study. We included every patient admitted for an elective diagnostic UGE under ketamine sedation who received lidocaine prior to the technique. Patients requiring any other medication were excluded. Our main outcome measure was the number of desaturation episodes. We then compared these results with those obtained in an historic group who did not receive topical lidocaine, in which we registered a total of 54 desaturation episodes.

RESULTS

In total, 88 children (52.3% boys) were included. The median age was 7 years [interquartile range (IQR) 3-11]. The mean duration of the procedure was 6.5 ± 2.4 min, and the median initial ketamine dose was 1.76 mg/kg (IQR 1.56-2.03). The total number of desaturation episodes was 3 (3.4%), and two of these occurred prior to the introduction of the endoscope. This result represents a lower incidence than in previously reported series, and a significant decrease (p < 0.0001) with respect to the 54 RAEs registered in the historic group of 87 children.

CONCLUSIONS

Topical lidocaine premedication significantly reduced the incidence of RAEs in children during UGEs under ketamine sedation. Our findings should be confirmed by a double-blind randomized controlled trial.

Anesthesia for interventional pulmonology procedures: a review of advanced diagnostic and therapeutic bronchoscopy

PURPOSE

Interventional pulmonology is a growing subspecialty of pulmonary medicine with flexible and rigid bronchoscopies increasingly used by interventional pulmonologists for advanced diagnostic and therapeutic purposes. This review discusses different technical aspects of anesthesia for interventional pulmonary procedures with an emphasis placed on pharmacologic combinations, airway management, ventilation techniques, and common complications.

SOURCE

Relevant medical literature was identified by searching the PubMed and Google Scholar databases for publications on different anesthesia topics applicable to interventional pulmonary procedures. Cited literature included case reports, original research articles, review articles, meta-analyses, guidelines, and official society statements.

PRINCIPAL FINDINGS

Interventional pulmonology is a rapidly growing area of medicine. Anesthesiologists need to be familiar with different considerations required for every procedure, particularly as airway access is a shared responsibility with pulmonologists. Depending on the individual case characteristics, a different selection of airway method, ventilation mode, and pharmacologic combination may be required. Most commonly, airways are managed with supraglottic devices or endotracheal tubes. Nevertheless, patients with central airway obstruction or tracheal stenosis may require rigid bronchoscopy and jet ventilation. Although anesthetic approaches may vary depending on factors such as the length, complexity, and acuity of the procedure, the majority of patients are anesthetized using a total intravenous anesthetic technique.

CONCLUSIONS

It is fundamental for the anesthesia provider to be updated on interventional pulmonology procedures in this rapidly growing area of medicine.

Effect of intravenous lidocaine on the incidence of postextubation laryngospasm: A double-blind, placebo-controlled randomized trial

Objectives

The study aimed to test the effect of intraoperative intravenous (IV) lidocaine on the incidence of postextubation laryngospasm in adult patients.

Methods

The prospective randomized clinical trial was conducted at tertiary care hospital in Riyadh, between January and December 2012. Seventy-two patients undergoing laparoscopic cholecystectomy were randomly assigned to receive either placebo (n = 36) or IV lidocaine (n = 36), 1 mg/kg bolus after desflurane was discontinued. Laryngospasm was graded from 0 to 3 based on the absence or presence of signs and the severity of postextubation laryngospasm.

Results

The study was terminated early by the data monitoring committee because of safety concerns due to an increased incidence of postextubation laryngospasm. Patient demographics were similar for both groups. The incidence of postextubation laryngospasm was 19.5% in the placebo group and 0% in the treatment (lidocaine) group; this difference was statistically significant (P = 0.017; 95% confidence interval, 4.6% to 36.0%).

Conclusions

The cause of laryngospasm in our study was most likely the rapid increase in the concentration of inspired desflurane, which might have caused airway irritation. Therefore, we believe that pretreating patients at risk of developing laryngospasm with IV lidocaine could be effective.

The Efficacy of Lidocaine in Laryngospasm Prevention in Pediatric Surgery: a Network Meta-analysis

Higher incidence and worse outcomes of laryngospasm during general anesthesia in children than adults have been reported for many years, but few prevention measures are put forward. Efficacy of lidocaine in laryngospasm prevention has been argued for many years and we decided to design this network meta-analysis to assess the efficacy of lidocaine. We conducted an electronic search of six sources and finally included 12 Randomized Controlled Trials including 1416 patients. A direct comparison between lidocaine and placebo revealed lidocaine had the effect on preventing laryngospasm in pediatric surgery (RR = 0.46, 95% CI = [0.30, 0.70], P = 0.0002, I² = 0%). Both subgroup analysis and network analysis demonstrated that both intravenous lidocaine (subgroup: RR = 0.39, 95% CI = [0.18, 0.86], P = 0.02, I² = 38%; network: RR = 0.25, 95% CI = [0.04, 0.86]) and topical lidocaine (subgroup: RR = 0.37, 95% CI = [0.19, 0.72], P = 0.003, I² = 0%; network: RR = 0.14, 95% CI = [0.02, 0.55]) was effective in laryngospasm prevention, while no statistical difference was found in a comparison between intravenous and topical lidocaine. In conclusion, both intravenous and topical lidocaine are effective in laryngospasm prevention in pediatric surgery, while a comparison between them needs more evidences.

Adult and pediatric anesthesia/sedation for gastrointestinal procedures outside of the operating room

PURPOSE OF REVIEW

This review presents current trends of safe and efficient anesthesia and sedation for adults and children for gastrointestinal procedures outside of the operating room with a special focus on total intravenous anesthesia (TIVA), target-controlled infusion (TCI), intravenous or topical lidocaine, and the use of the video laryngoscope.

RECENT FINDINGS

The concepts of a well tolerated and adequate anesthesia or sedation for gastrointestinal procedures outside of the operating room have to meet the needs of the adult and pediatric patients and the special requests of the gastroenterologists. Anesthesia and sedation of adults for gastrointestinal procedures with TIVA or TCI and spontaneous breathing is well established. Many institutions perform anesthesia for pediatric patients undergoing gastrointestinal procedures with an inhalational agent, especially in young children and for short procedures. Unlike adults, in young children the airways frequently must be secured with a tracheal tube or laryngeal mask. Respiration may be spontaneous, assisted, or controlled. TIVA and TCI are increasingly chosen for older children and longer procedures. A local anesthetic administered intravenously or topically to the upper airways and the use of the video laryngoscope can facilitate the insertion of the endoscope.

SUMMARY

Both anesthesiologists and nonanesthesiologists have to achieve a consensus and develop quality-improvement strategies to provide safe and efficient anesthesia and sedation for gastrointestinal procedures outside of the operating room for pediatric and adult patients. Techniques using TIVA, TCI, intravenous or topical application of lidocaine, and the video laryngoscope may improve and facilitate gastrointestinal procedures for the patients, the anesthesiologists, and the gastroenterologists.

Lignocaine topicalization of the pediatric airway

The application of topical laryngeal lignocaine is a technique used frequently in pediatric anesthesia. It is often used to facilitate open airway procedures, tracheal intubation, or to reduce the incidence of perioperative adverse respiratory events such as coughing and laryngospasm. A number of studies have shown that applying topical lignocaine to the larynx reduces perioperative respiratory adverse events, while others have shown an increased incidence of respiratory complications with lignocaine administration. There is a lack of evidence on the effect of topical lignocaine on the sensitivity of upper airway reflexes and swallowing, the duration of time that airway reflexes are obtunded, and the optimum and safe maximum dose of lignocaine when used by this route. We review the current literature relating to the use of lignocaine to topicalize the pediatric airway. This review concentrates on the indications for use, the maximum safe dose, the effect on swallowing, and risk of aspiration and the complications of the technique.

Pre-emptive peritonsillar infiltration of magnesium sulphate and ropivacaine vs. ropivacaine or magnesium alone for relief of post-adenotonsillectomy pain in children

OBJECTIVES

The randomized, double-blinded, placebo-controlled study evaluated the administration of local infiltration of magnesium combined with ropivacaine to reduce pain scores after pediatric adenotonsillectomy.

METHODS

Sixty one subjects received 5ml solution contained 0.25% ropivacaine plus 5mg/kg magnesium sulphate (Group M+R), 5ml 0.25% ropivacaine (Group R) or 5ml solution contained 5mg/kg magnesium sulphate (Group M). Pain scores in the ward and at home, analgesics received after operation and the adverse effects were recorded.

RESULTS

Compared with group M, patients in group M+R and group R had lower pain scores, less emergence agitation and increased time for first analgesic request. Group M+R had no benefit in reducing pain scores after adenotonsillectomy compared with group R.

CONCLUSIONS

Pre-emptive peritonsillar infiltration of magnesium sulphate 5mg/kg combined with 0.25% ropivacaine couldn't improve analgesia for pediatric adenotonsillectomy compared with 0.25% ropivacaine alone. However, Group M+R had less incidence of emergence agitation. Compared with group M, both of group M+R and group R had better postoperative analgesia.