Lidocaine exerts its effect on induced bronchospasm by mitigating reflexes, rather than by attenuation of smooth muscle contraction

Perioperative Care of the Pediatric Patient and an Algorithm for the Treatment of Intraoperative Bronchospasm

Asthma remains a common comorbid condition in patients presenting for anesthetic care. As a chronic inflammatory disease of the airway, asthma is known to increase the risk of intraoperative bronchospasm. As the incidence and severity of asthma and other chronic respiratory conditions that alter airway reactivity is increasing, a greater number of patients at risk for perioperative bronchospasm are presenting for anesthetic care. As bronchospasm remains one of the more common intraoperative adverse events, recognizing and mitigating preoperative risk factors and having a pre-determined treatment algorithm for acute events are essential to ensuring effective resolution of this intraoperative emergency. The following article reviews the perioperative care of pediatric patients with asthma, discusses modifiable risk factors for intraoperative bronchospasm, and outlines the differential diagnosis of intraoperative wheezing. Additionally, a treatment algorithm for intraoperative bronchospasm is suggested.

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.

Oral dyclonine hydrochloride mucilage versus tetracaine spray in electronic flexible laryngoscopy: A prospective, randomized controlled trial

BACKGROUND

Topical anesthesia is important for electronic flexible laryngoscopy (EFL) utilization. We hypothesized that oral dyclonine hydrochloride mucilage (ODHM) is superior to tetracaine spray (TS) in patients undergoing EFL examination.

METHODS

This study included 932 patients randomized into either an ODHM or TS group, in which patients received either a single utilization of ODHM or TS administered via spray in three intervals. A 4.9 mm diameter flexible PENTAX-VNL-1570STK insertion tube placed into a Naso-Pharyngo-Laryngoscope (PENTAX Medical, Japan) was used in the procedure. Visual analogue scale (VAS) (0-10) was used to evaluate patient tolerance and procedure success by the operator, independently. Procedure time was also recorded.

RESULTS

Both patients' and doctors' VAS scores were significantly higher in the ODHM group compared to the TS group. When subgroup analysis was made according to the procedure length (100 s), there was no significant difference in VAS between ODHM and TS groups in the short time procedure (≤100 s), while VAS in the ODHM group was higher compared to the TS in the long time procedure (>100 s), as assessed by both patients and doctors.

CONCLUSION

A single use of ODHM seems to be superior to three doses of TS in patients undergoing EFL, specifically in procedures longer than 100seconds.

Effects of different bronchoalveolar lavage methods on tracheobronchial foreign body patients

OBJECTIVES/HYPOTHESIS

To compare the different effects of bronchoalveolar lavage (BAL) with diverse combinations of lidocaine, epinephrine, and dexamethasone on pediatric patients with an inhaled tracheobronchial foreign body (TFB).

STUDY DESIGN

Randomized controlled study.

METHODS

Two hundred forty cases of pediatric patients with inhaled TFB were included in this study, and were randomly divided into four groups using three kinds of drugs for BAL, namely 0.9% saline (S) group, 2% lidocaine with diluted epinephrine (LE) group, 2% lidocaine with diluted epinephrine and 0.5% dexamethasone (LED), control group (C) without BAL. The incidences of intraoperative or postoperative complications and recovery periods were compared. Meanwhile, the concentrations of interleukin (IL)-1β, IL-6, and tumor necrosis factor (TNF)-α in BAL fluids and plasma were evaluated by enzyme-linked immunosorbent assay.

RESULTS

The incidences of bronchospasm, hypoxemia, and postoperative fever were significantly lower in the LED group than other groups (P < .001). Fever after the TFB removal procedure appeared later in the LED group than the other groups. The improvement and healing periods in the LE and LED groups were significantly shorter than those in the C and S groups (P < .001). The concentrations of IL-1β, IL-6, and TNF-α in BAL fluids were significantly higher in the LE and LED groups than those in the S group (P < .001), but those in the plasma of the C and S groups were lower compared with the LE and LED groups (P < .001).

CONCLUSIONS

BAL with lidocaine, epinephrine, and dexamethasone could promote recovery for TFB patients and reduce incidences of complications, possibly by regulating release of proinflammatory cytokines.

LEVEL OF EVIDENCE

1b.

Intravenous lidocaine increases the depth of anaesthesia of propofol for skin incision--a randomised controlled trial

BACKGROUND

The anaesthetic potency of intravenous propofol is quantified by its Cp50 value, which is defined as the plasma concentration required to prevent movement response in 50% of patients to surgical stimuli. We hypothesised that, in addition to propofol anaesthesia, an intravenous bolus of lidocaine 1.5 mg/kg will decrease the Cp50 value of propofol during anaesthesia.

METHODS

We enrolled 54 elective surgical patients undergoing propofol-based anaesthesia, and randomised them to either lidocaine 1.5 mg/kg, lidocaine 0.5 mg/kg or placebo (NaCl 0.9%) 3 min before skin incision. The propofol Cp50 value was then calculated using the 'up-and-down' method of Dixon and Massey.

RESULTS

There was no significant reduction in propofol requirements after the administration of 0.5 mg/kg lidocaine from 8.5 μg/ml [confidence interval (CI) 6.0-11.625] to 8.25 μg/ml (CI 6.75-9.76); however, a bolus of 1.5 mg/kg lidocaine decreased the Cp50 value of propofol by 42% from 8.5 μg/ml (CI 6.0-11.625) to 4.92 μg/ml (CI 4.5-5.78) (P < 0.05).

CONCLUSION

An intravenous bolus injection of 1.5 mg/kg lidocaine 2% caused a significant reduction of the propofol Cp50 value.

Nebulized lidocaine blunts airway hyper-responsiveness in experimental feline asthma

Nebulized lidocaine may be a corticosteroid-sparing drug in human asthmatics, reducing airway resistance and peripheral blood eosinophilia. We hypothesized that inhaled lidocaine would be safe in healthy and experimentally asthmatic cats, diminishing airflow limitation and eosinophilic airway inflammation in the latter population. Healthy (n = 5) and experimentally asthmatic (n = 9) research cats were administered 2 weeks of nebulized lidocaine (2 mg/kg q8h) or placebo (saline) followed by a 2-week washout and crossover to the alternate treatment. Cats were anesthetized to measure the response to inhaled methacholine (MCh) after each treatment. Placebo and doubling doses of methacholine (0.0625-32.0000 mg/ml) were delivered and results were expressed as the concentration of MCh increasing baseline airway resistance by 200% (EC200Raw). Bronchoalveolar lavage was performed after each treatment and eosinophil numbers quantified. Bronchoalveolar lavage fluid (BALF) % eosinophils and EC200Raw within groups after each treatment were compared using a paired t-test (P <0.05 significant). No adverse effects were noted. In healthy cats, lidocaine did not significantly alter BALF eosinophilia or the EC200Raw. There was no difference in %BALF eosinophils in asthmatic cats treated with lidocaine (36±10%) or placebo (33 ± 6%). However, lidocaine increased the EC200Raw compared with placebo 10 ± 2 versus 5 ± 1 mg/ml; P = 0.043). Chronic nebulized lidocaine was well-tolerated in all cats, and lidocaine did not induce airway inflammation or airway hyper-responsiveness in healthy cats. Lidocaine decreased airway response to MCh in asthmatic cats without reducing airway eosinophilia, making it unsuitable for monotherapy. However, lidocaine may serve as a novel adjunctive therapy in feline asthmatics with beneficial effects on airflow obstruction.

Topical lidocaine reduces the risk of perioperative airway complications in children with upper respiratory tract infections

PURPOSE

To determine the effect of topically applied lidocaine on perioperative airway complications when using a laryngeal mask airway device (LMAD) in children either with or without a history of recent or ongoing upper respiratory tract infection (URI).

METHODS

In a randomized controlled double-blind trial, 34 children with a history of recent or ongoing URI and 32 non-URI children- all of whom were younger than age ten and scheduled to undergo minor surgical procedures-were randomly assigned to either a lidocaine or a placebo group. In the lidocaine group, an LMAD was lubricated with lidocaine gel before insertion, and a clear lubricating gel was used in the placebo group. The following data were recorded after standardized anesthesia induction and airway management: postoperative complications, such as coughing, desaturation, laryngospasm, and increased oral secretions, as well as length of stay in the postanesthetic recovery unit.

RESULTS

Children with URI had a lower overall perioperative complication rate if they received a lidocaine gel (35%) rather than placebo (94%) (P < 0.01). Also, the incidence of postoperative coughing was less (12% vs 53%; P = 0.03). In non-URI patients, lidocaine did not significantly reduce the rate of airway complications compared with placebo (17% vs 24%, respectively).

CONCLUSION

Lubrication of the LMAD with lidocaine gel reduces the incidence of airway complications in children with an upper respiratory tract infection.

The effects of lidocaine and fentanyl on airway irritability during inhalation induction with desflurane

BACKGROUND

Inhalation induction with desflurane can cause airway irritability and sympathetic stimulation. The aim of this study was to investigate whether lidocaine and fentanyl could reduce these unwanted reactions.

METHODS

Seventy-five patients who had premedication with midazolam were randomly allocated to one of three groups to receive intravenous saline (S group), lidocaine 1.5 mg/kg (L group), fentanyl 1 microgram/kg (F group), respectively, before tidal volume induction with desflurane in oxygen and nitrous oxide. We recorded airway irritability such as cough, apnea, laryngospasm and excitatory movement and hemodynamic changes.

RESULTS

Airway irritability was not significantly different between the groups. In F group, mean blood pressure at LOC ver and LOC BIS and heart rate at LOC ver, LOC BIS and just before intubation were lower than those of S group (P < 0.05). Other results were not significantly different.

CONCLUSIONS

The results of the study showed that intravenous fentanyl and lidocaine had no beneficial effects to reduce airway irritability, but intravenous fentanyl could significantly reduce hemodynamic stimulation during inhalation induction with desflurane in the patients who were premedicated with midazolam.