Lignocaine topicalization of the pediatric airway

Airway topicalization in pediatric anesthesia: An international cross-sectional study

BACKGROUND

There is no national or international consensus or guideline on recommended dosing of lidocaine for airway topicalization in children. Doses quoted in the literature vary substantially.

AIMS

The primary aim of the study was to ascertain current international dosing practices (mg.kg-1 and concentration of solution) for lidocaine airway topicalization in children. The secondary aims included examining aftercare instructions for those receiving lidocaine airway topicalization and instances of local anesthetic systemic toxicity secondary to the use of lidocaine for airway topicalization in pediatric patients.

METHODS

This cross-sectional study consisted of 11-20 questions across three domains-population demographics, clinical practice, and local anesthetic systemic toxicity. It adhered to the consensus-based checklist for reporting of survey studies. Responses were collected over 14 weeks using a combination of probability (cluster and simple random) and nonprobability (purposive, convenience and snowball) sampling. Data were analyzed based on the response rate per question with proportions expressed as percentages and nonparametric data expressed as median (interquartile range [range]) in an effort to minimize nonresponse error. No weighting of items or propensity scoring was applied.

RESULTS

After initial exclusions, 1501 participants from 69 countries, across six continents, were included. Consultant anesthetists or those with an equivalent level of experience accounted for 1262/1501 (84.1%) of responses. Results showed heterogeneity in dosing and timing regimens and evidence that dosing may contribute to adverse outcomes. The maximum dose reported by participants who use lidocaine for airway topicalization as part of their normal practice was 5 mg.kg-1 (4-6 mg.kg-1 [0.5-50]) median (interquartile range [range]) over 2 h (1-4 h [0-30]).

CONCLUSION

The results support the need for further research and consensus in this area, in order to provide safe provision of lidocaine airway topicalization in children. It is hoped the results of this study can support future collaborative work in this area.

Pediatric anesthetic for tracheobronchial foreign body extraction: A survey of practice in France

BACKGROUND

Tracheobronchial foreign body aspiration is a classic pediatric emergency, and its associated morbidity particularly depends on the anesthetic management, which differs according to the center and the practitioner.

AIMS

The aim of this study was to evaluate the different anesthetic practices for tracheobronchial foreign body extraction.

METHODS

A survey was sent via email to the member physicians of the Association des Anesthésistes Réanimateurs Pédiatriques d'Expression Française (ADARPEF). The survey included 28 questions about the organizational and anesthetic management of an evolving clinical case.

RESULTS

A total of 151 physicians responded to the survey. Only 13.2% of the respondents reported that their institution had a management protocol, and 21.7% required a computerized tomography scan before the procedure was performed for children who were asymptomatic or mildly symptomatic during the night. There were 56.3% of the respondents who reported that extraction with a rigid bronchoscope is the only procedure usually performed in their institution. Regarding rigid bronchoscopy, 47.0% used combined intravenous-inhalation anesthesia. The objective was to maintain the child on spontaneous ventilation for 63.6% of the respondents, but anesthesia management differed according to the physician's experience.

CONCLUSIONS

Our study confirms the diversity of practices concerning anesthetic for tracheobronchial foreign body extraction and found reveal differences in practice according to physician experience.

Risk assessment and optimization strategies to reduce perioperative respiratory adverse events in Pediatric Anesthesia-Part 2: Anesthesia-related risk and treatment options

Perioperative respiratory adverse events are the most common cause of critical events in children undergoing anesthesia and surgery. While many risk factors remain unmodifiable, there are numerous anesthetic management decisions which can impact the incidence and impact of these events, especially in at-risk children. Ongoing research continues to improve our understanding of both the influence of risk factors and the effect of specific interventions. This review discusses anesthesia risk factors and outlines strategies to reduce the rate and impact of perioperative respiratory adverse events with a chronologic based inquiry into anesthetic management decisions through the perioperative period from premedication to postoperative disposition.

Less Exposure for Health Care Workers, More Comfort for Patients During COVID-19 Swab Testing

BACKGROUND

Nasopharyngeal (NP) and oropharyngeal (OP) swab sampling for coronavirus disease 2019 (COVID-19) diagnosis may lead to droplet and/or airborne particle transmission and increase the exposure risk for health care workers (HCWs). However, there is limited evidence for effective methods to reduce occupational exposure from NP and OP swab sampling. This study aimed to reduce droplet-forming responses (DFRs) and the related exposure risk of NP and OP swab sampling by administering 10% lidocaine spray (LS) to the NP and OP areas prior to conducting swab tests.

METHODS

This quasi-experimental study was conducted with 100 patients who presented to our tertiary care hospital with symptoms of COVID-19 between December 1 and 15, 2020. First, NP and OP swabbings were performed on each patient. Thereafter, LS was applied to the OP and NP regions, and the swab samples were taken once again. Frequency of DFRs and real-time polymerase chain reaction (RT-PCR) test results before and after LS application were recorded for comparison. In addition, the cycle threshold (Ct) was used as a proxy indicator for SARS-CoV-2 viral load in COVID-19 positive cases.

FINDINGS

Significant differences in OP DFR frequencies before and after LS intervention were found (37% and 9%, respectively), as well as before and after NP DFR (31% and 18%, respectively). The mean Ct values for the positive samples did not differ before and after applying LS.

CONCLUSION

Our results suggest that applying LS to the OP and NP area prior to swab testing reduces DFR frequencies without affecting (RT-PCR) test results for SARS-CoV-2 and may increase patient and practitioner comfort.

Acute Respiratory Failure With a Rare, Rapidly Progressing Pediatric Desmoid Tumor Anterior Mediastinal Mass

ABSTRACT

We present an unusual case of a 6-year-old boy who presented with the sudden presence of left neck mass and acute hypoxemic respiratory failure, whose subsequent imaging demonstrated a previously undiagnosed anterior mediastinal mass (AMM) extending into the left neck. Biopsy of the mass was consistent with a desmoid tumor, which is a rare cause of AMM in children. Desmoid tumors are locally aggressive, often invading and enveloping surrounding tissues, but overall slow growing. The sudden growth of the neck mass suggests a very aggressive desmoid tumor, causing an unexpected respiratory compromise. Anterior mediastinal masses may cause symptoms by compressing the heart, great vessels, and airways. However, the patient may adapt and develop compensatory mechanisms to counter the compressive effects. Emergency care of the patient with an AMM who presents with acute respiratory distress includes optimizing oxygenation through promoting a calm environment, oxygenating while minimizing positive end-expiratory pressure, maintaining the patient's compensatory mechanisms by minimizing sedation and muscle relaxation, positioning the patient to minimize compressive effects of the mass on the vital thorax structures, and early consultation with pediatric specialists to develop a shared-emergency treatment strategy and to secure an expedited disposition to the appropriate venue of care.

Airway Anesthesia for Awake Tracheal Intubation: A Review of the Literature

Airway topicalization is frequently utilized by anesthesiologists to facilitate open airway procedures, aid intubation for a difficult airway, and prevent adverse respiratory events. This review article summarizes the techniques available for airway topicalization for a patient who is deemed to be difficult to intubate. We focus on the indications for use, local anesthetic maximum dosages and safety profiles, sedation techniques, and trials and pitfalls during airway topicalization for difficult intubation.

LID Study: Plasma lidocaine levels following airway topicalisation for paediatric microlaryngobronchoscopy (MLB)

BACKGROUND

A dose of 5mg/kg lidocaine is considered appropriate for paediatric airway topicalisation. Existing literature suggests younger children are susceptible to toxic lidocaine plasma levels and achieve this at a faster rate.

AIMS

The primary outcome of this study was to ascertain peak plasma lidocaine levels after topicalisation for airway endoscopy. Secondary endpoints included: time to peak lidocaine plasma levels, signs of lidocaine toxicity (restricted to ECG changes or seizures when under anaesthesia) and clinical adverse events of laryngospasm, coughing or desaturation during the procedure.

METHODS

Data was collected prospectively over 18 months at Royal Manchester Children's Hospital. Children aged 0-8 years undergoing elective diagnostic or therapeutic airway endoscopy were included within the study. Standardised 2% lidocaine was used for airway topicalisation. Dose varied depending upon practitioner usual practice. Venous blood sampling occurred at 5, 10, 15 and 20 minutes post administration and plasma lidocaine levels (ng/ml) analysed.

RESULTS

A significant relationship exists between higher peak plasma levels and ages <18 months (p=0.00973). Strong linear correlation exists between body weight and age for our cohort (r=0.88). Higher peak plasma lidocaine levels occur with total dose volumes between 2 and 3mls of 2% lidocaine local anaesthetic (p=0.03) compared with <2ml total dose volumes. Data suggests a potential relationship of lower body weights achieving higher peak plasma levels (p=0.0516). Reduced IQR variation of peak plasma lidocaine levels exists when lidocaine dosing is <5mg/kg.

CONCLUSIONS

Age and total dose volume of topicalised lidocaine have a significant relationship with plasma lidocaine levels. A dose of 5mg/kg topicalised lidocaine for paediatric airway endoscopy is safe and provides good operating conditions. Lower patient body weights trend toward higher peak lidocaine plasma concentrations and require further investigation.

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.

Awake fiberoptic orotracheal intubation: a protocol feasibility study

Objective

To assess the feasibility of an awake fiberoptic intubation (AFOI) protocol.

Methods

We enrolled 40 patients with simulated difficult intubation. The protocol consisted of conscious sedation (midazolam, 0.03 mg/kg and sufentanil, 0.1 µg/kg), regional anesthesia, and intubation. The time, first-attempt intubation success rate, hemodynamic parameters, blood oxygen saturation (SpO₂), intubation amnesia rate, patient satisfaction, and relative complications were recorded.

Results

AFOI was completed in all patients. The average total AFOI time was 14.17 ± 1.47 minutes, and the time to placing the landmark-guided bilateral superior laryngeal nerve block was 1.24 ± 0.42 minutes. The first-attempt intubation success rate was 97.5%, and patient satisfaction was 90%. Blood pressure changed (<20%) briefly after administering conscious sedation. Heart rates did not change significantly, and SpO₂ remained stable and ≥95%. Three patients had a sore throat, which resolved on postoperative day 1 without other complications. On postoperative day 1, 82.5% (33/40) of the patients had no recall of AFOI, and 17.5% (7/40) had only an indistinct memory.

Conclusions

The protocol was feasible with a high first-attempt intubation success rate and low complications rate. Hemodynamic parameters and respiration remained stable, with high patient satisfaction and effective amnesia.

Management of the Unexpected Difficult Airway in Neonatal Resuscitation

A "difficult airway situation" arises whenever face mask ventilation, laryngoscopy, endotracheal intubation, or use of supraglottic device fail to secure ventilation. As bradycardia and cardiac arrest in the neonate are usually of respiratory origin, neonatal airway management remains a critical factor. Despite this, a well-defined in-house approach to the neonatal difficult airway is often lacking. While a recent guideline from the British Pediatric Society exists, and the Scottish NHS and Advanced Resuscitation of the Newborn Infant (ARNI) airway management algorithm was recently revised, there is no Norwegian national guideline for managing the unanticipated difficult airway in the delivery room (DR) and neonatal intensive care unit (NICU). Experience from anesthesiology is that a "difficult airway algorithm," advance planning and routine practicing, prepares the resuscitation team to respond adequately to the technical and non-technical stress of a difficult airway situation. We learned from observing current approaches to advanced airway management in DR resuscitations in a university hospital and make recommendations on how the neonatal difficult airway may be managed through technical and non-technical approaches. Our recommendations mainly pertain to DR resuscitations but may be transferred to the NICU environment.

Oxygen desaturation and time burden during tracheobronchial endoscopy for suspected foreign body in toddlers

Tracheobronchial endoscopy with general anaesthesia for suspected foreign body aspiration exposes toddlers to acute hypoxemia. Better quantification of intraoperative hypoxemia could help identify and manage the most severe patients. We explored the hypoxic burden approach to account for both duration and depth of desaturation episodes during the procedure and determined risk factors for high hypoxic burden. We retrospectively analysed tracheobronchial endoscopies performed from September 2015 to September 2018 in children ≤ 36 months for suspected foreign body aspiration, in two French university hospitals. The hypoxic burden (area under 90% of the SpO₂/time curve) was calculated. The median of non-zero burdens was used to delineate a subgroup with high hypoxic burden. Risk factors for high hypoxic burden were identified using multivariable analysis. Of 96 procedures, 56 (58%) were associated with at least one SpO₂ value < 90%. Of them, the median [interquartile] hypoxic burden was 25 [5-87] %.min. Bradycardia < 100 bpm occurred in 11 procedures (11%). Initial admission to general hospitals (OR 0.23, 95% CI 0.06-0.86) and airway anaesthesia with topical lidocaine (OR 0.15, 95% CI 0.03-0.62) were associated with a reduced risk of high hypoxic burden. High hypoxic burden was associated with an increased risk of postoperative invasive ventilation (OR 32, 95% CI 1.7-617) and of hospital stay > 24 h (OR 4.0, 95% CI 1.6-10). No postoperative neurological sequelae were found. The hypoxic burden approach, when applied in tracheobronchial endoscopy for suspected foreign body aspiration in toddlers, enabled the quantification of hypoxemia and the search for specific risk factors.

Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults

Awake tracheal intubation has a high success rate and a favourable safety profile but is underused in cases of anticipated difficult airway management. These guidelines are a comprehensive document to support decision making, preparation and practical performance of awake tracheal intubation. We performed a systematic review of the literature seeking all of the available evidence for each element of awake tracheal intubation in order to make recommendations. In the absence of high‐quality evidence, expert consensus and a Delphi study were used to formulate recommendations. We highlight key areas of awake tracheal intubation in which specific recommendations were made, which included: indications; procedural setup; checklists; oxygenation; airway topicalisation; sedation; verification of tracheal tube position; complications; management of unsuccessful awake tracheal intubation; post‐tracheal intubation management; consent; and training. We recognise that there are a range of techniques and regimens that may be effective and one such example technique is included. Breaking down the key practical elements of awake tracheal intubation into sedation, topicalisation, oxygenation and performance might help practitioners to plan, perform and address complications. These guidelines aim to support clinical practice and help lower the threshold for performing awake tracheal intubation when indicated.

Failed videolaryngoscopy in an infant with giant vallecular cyst managed successfully with a 'three-person technique' of fibre-optic intubation

Vallecular cysts are a rare entity but can complicate the airway management due to the physical impediment and distortion of the laryngeal inlet. It can lead to fatal life-threatening airway obstruction postinduction of anaesthesia. Infancy compounds the risks due to lack of cooperation and physiological reserves. The literature review suggested most anaesthesiologists avoided muscle relaxants and aspiration of the cyst was used as a rescue technique. The present case report illustrates the successful airway management of an infant with a huge vallecular cyst using fibre-optic intubation by a 'three-person' technique after paraglossal videolaryngoscopy failed to secure the airway.

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.

On-table extubation in neonates undergoing anoplasty: an experience of anesthetic management on the concept of fast-tracking anesthesia: A pilot study

Fast-track anesthesia (FTA) is difficult to achieve in neonates due to immature organ function and high rates of perioperative events. As a high-risk population, neonates require prolonged postoperative mechanical ventilation, which may lead to contradictions in cases where neonatal intensive care unit resources and ventilator facilities are limited. The choice of anesthesia strategy and anesthetic can help achieve rapid postoperative rehabilitation and save hospitalization costs. The authors describe their experience with maintaining spontaneous breathing in neonates undergoing anoplasty without opioids or muscle relaxants.This retrospective chart review included neonates who underwent anoplasty in the authors' institution. Twelve neonates who underwent the procedure with atomized 5% lidocaine topical anesthesia around the glottis, combined with sevoflurane sedation and caudal anesthesia facilitating tracheal intubation without opioid and muscle relaxant comprised the FTA group. Ten neonates who underwent the intervention with routine anesthesia techniques in the same period comprised the control group (group C).The surgical success rate in the FTA group was 91.7%. There were no severe complications related to lidocaine administered around the glottis. Extubation time was significantly shorter in the FTA group than in group C (4 [2.5, 5.2] vs 81.5 [60.6, 96.8], respectively; P < .01). The duration of stay in the surgical intensive care unit (SICU) was longer in group C than in the FTA group (2 [2.0, 2.6] vs 1 [0.9, 2.0], respectively; P = .006,). A statistically significant lower rate of extubation-cough was noted after endotracheal tube removal in the FTA group compared with group C (18% vs 90%, respectively; P < .001). There was no difference in the duration of anesthesia or hospitalization costs between the 2 groups. No neonates required re-intubation after extubation.On-table extubation via 5% atomized lidocaine topical anesthesia around the glottis for tracheal intubation combined with sevoflurane sedation and caudal anesthesia without opioid and muscle relaxant was feasible in neonates undergoing anoplasty. This reduced time to extubation, length of SICU stay and saved resources. A similar trend in cost savings was also found; nevertheless, more studies are needed to confirm these results.

Entrapment of a laryngotracheal topical anesthesia kit during tracheobronchial foreign body removal: a case report

Background

In order to reduce the irritation of the airway during tracheobronchial foreign body (TFB) removal, tracheal surface anesthesia is usually performed using a laryngotracheal topical anesthesia (LTA) kit (LTA20, Highgreen Medical Technology Company, China), but difficulty in withdrawing the LTA kit is rarely reported. We present a case of a difficulty to withdraw the LTA kit due to its entrapment by the movement of a TFB.

Case presentation

A 1-year-old girl was undergoing TFB removal. After the surgeon completed the tracheal surface anesthesia, the girl suddenly suffered from bucking, leading to the dislodgment of the TFB to the subglottic region, complicating the withdrawal of the LTA applicator. At the same time, the girl’s oxygen saturation (SpO₂) decreased to 91% and her heart rate dropped from 150 to 100 bpm. Atropine and succinylcholine were administered intravenously immediately, then the surgeon tried to free the TFB by pushing it back into the trachea, after which the LTA applicator was easily withdrawn, and TFB was removed successfully. The girl was discharged from hospital without any complications 2 days later.

Conclusion

This case report draws our attention to a significant anesthetic clinical consideration during the application of topical anesthesia on the trachea for TFB removal. The possibility of coughing or bucking can lead to migration of the TFB with subsequent airway obstruction, so the depth of anesthesia must be sufficient to prevent harmful reflexes. Also, strong teamwork and good communication are paramount to avoid serious complications.