Lidocaine and the Prevention of Emergence Phenomena - PowerPoint Presentation

Slide1

Lidocaine and the Prevention of Emergence Phenomena

Ian Lynch & Daniel Parker

Gonzaga University

Providence Sacred Heart Medical Center

March 20, 2014Slide2

Statement of Problem

A common goal of anesthesia providers is to have a smooth emergence during extubation without coughing

Emergence from anesthesia is managed differently by each anesthesia provider

Traditional methods of EP prevention including: deep extubation, IV lidocaine, LTA, and lidocaine ointment/jelly on ETT cuff

New methods of topical tracheal anesthesia may prove beneficial for reducing EPSlide3

Emergence Phenomenon (EP)

A phenomenon that includes coughing, sore throat, or

dysphonia

, or a combination of all three, as a result of an

endotracheal

tube cuff irritating the tracheal mucosa during emergence Slide4

Purpose Statement

The purpose of this study was to assess, through survey, the current professional practice among CRNAs regarding their treatment modalities for reducing emergence phenomenon (EP) for general endotracheal anesthesia in the operating roomSlide5

Guiding Research Questions

What

are surveyed CRNAs doing to prevent EP?

To

what degree are practitioners familiar with

the

use of

lidocaine

filled

endotracheal

tube

cuff

(ETTC)?

How

does an ETTC filled with

lidocaine

compare

to other treatment modalities?

What

are the risks and benefits of

various treatment

modalities for EP?Slide6

Review of the Literature

Emergence Phenomena

Postoperative sore throat is the most common complaint after endotracheal intubation

(Estebe et al., 2004)

Presumed mechanisms of EP include irritation or stretch stimuli directly to the trachea from an ETT or cuff

(Fegan et al., 2000)

Current treatments to avoid EP include local anesthetics via a variety of different delivery methods

(Minogue, Ralph, &

Lampa

, 2004)Slide7

Review of the Literature

Current Emergence Phenomenon Reduction Strategies

IV lidocaine 60-90 seconds prior to intubation

1 and 1.5 mg/kg IV decreases sore throat and cough

(

Takekawa

, Yoshimi, and Kinoshita, 2006)

2 mg/kg IV complete cough suppression

(

Yukioka

et al.,1985)

Superior to LTA at attenuating CV response to intubation

(Youngberg, Graybar, and Hutchings, 1983), Hamill, Bedford, Weaver, and

Colohan

, 1981)

Prevents increases in ICP while LTA did not

(Hamill, Bedford, Weaver, and

Colohan

, 1981)Slide8

Current Emergence Phenomenon

Reduction Strategies

LTA: Topical anesthesia applied prior to intubation has little to no effect on prevention of coughing during extubation

(

Diachun

,

Tunink

, & Brock-

Utne

, 2001

)

LTA: surgeries <2 hours

Decreased cough by 26% prior to extubation compared to saline spray control

(Minogue, Ralph, and Martin, 2004)

LITA: Administration of four percent lidocaine via LITA, 30 minutes prior to extubation results in a significant reduction in ETT induced coughing during emergenceSlide9

Review of the Literature

Current Emergence Phenomenon Reduction Strategies

Lidocaine 1mg/kg down ET vs. IV three minutes prior to extubation

ET significantly decreased cough while IV did not

(

Jee

and Park, 2003)

Lidocaine spray

Additives caused postoperative sore throat and hoarseness

(Hara and Maruyama, 2005)

Jelly

Complete ET obstruction with sheet-like film

(Uehira, Tanaka,

Mitsugu

,

Oda

, and Sato, 1981)

Sore throat worse than saline (85 vs 62%)

(

Klemola

,

Saaenivaara

, and

Yrjola

, 1988) Slide10

Review of the Literature

Alkalized Lidocaine filled ETTC

Time:

60 minutes or longer of alkalized lidocaine filling the ETT is required for noticeable cough suppression

(Fagan et al., 2000)

Addition of Sodium Bicarbonate:

By increasing the pH of a solution, you can predictably increase the percentage of the non-ionized fraction of the drug

Lidocaine Concentration:

Low doses of lidocaine, even as low as 40 mg, with the addition of bicarbonate, showed better outcomes with EP prevention when compared to higher dose, non-alkalinized solutions

(Estebe et al, 2005)

Efficacy and Safety:

Lower concentrations of sodium bicarbonate are equally as effective as using the higher dose of 8.4% and are saferSlide11

Methodology

Qualitative study

Survey created utilizing SurveyMonkey

Survey distributed to CRNAs via state associations of nurse anesthetists

Participating states: AZ, CA, CO, DC, ID, KS, KY, MA, MO, MT, OK, OR, RI, SC, TN, TX, UT, VA, WA

All 50 state associations were invited to participateSlide12

FindingsSlide13

FindingsSlide14

FindingsSlide15

FindingsSlide16

Findings n=9Slide17

FindingsSlide18

Recommendations

ETTC filled with alkalized lidocaine has been shown to prevent EP more effectively that other techniques as well as be a safe alternative

Providers should use a manometer each time they fill the ETTC

Achieve correct occlusive cuff pressure using air

Remove and measure the amount of air required to reach said pressure and record this number

Add 2mls of 2% lidocaine

Add 1-2mls of sodium bicarbonate

Add as much NS as is required to match the cuff volume withdrawn to reach desired or occlusive pressureSlide19

References

Diachun

, C. A.,

Tunink

, B., & Brock-

Utne

, J. G. (2001). Suppression of Cough During Emergence From General Anesthesia: Laryngotracheal Lidocaine Through a Modified Endotracheal Tube.

Journal of Clinical Anesthesia

,

13

, 447-450.

Estebe, J. P.,

Delahaye

, S., Le

Corre

, P.,

Dollo

, G., Le

Naoures

, A.,

Chevanne

, F., &

Ecoffey

, C. (2004).

Alkalinization

of intra-cuff lidocaine and use of gel lubrication protect against tracheal tube-induced emergence phenomena.

British Journal of

Anaesthesia

,

92

, 361-366. http://dx.doi.org/10.1093/bja/aeh078

Estebe, J. P.,

Gentili

, M., Le

Corre

, P.,

Dollo

, G.,

Chevanne

, F., &

Ecoffey

, C. (2005).

Alkalinization

of

Intracuff

Lidocaine: Efficacy and Safety.

Anesthesia and Analgesia

,

101

, 1536-1541.

Fagan, C.,

Frizelle

, H.,

Laffey

, J., Hannon, V., Carey, M. (2000). The Effects of

Intracuff

Lidocaine on Endotracheal-Tube-Induced Emergence Phenomena after general anesthesia.

Anesthesia and Analgesia

,

91

, 201-205.

Hamill, J. F.,

Bedord

, R. F., Weaver, D. C.,

Colohan

, A. R. (1981). Lidocaine before Endotracheal Intubation: Intravenous or laryngotracheal?

Anesthesiology

,

55

, 578-581.Slide20

References

Hara, K., & Maruyama, K. (2005). Effect of additives in lidocaine spray on postoperative sore throat, hoarseness and dysphagia after total intravenous

anaesthesia

.

Acta

Anaesthesiologica

Scandinavica

,

49

, 463-467.

Jee

, D., & Park, Y. (2003). Lidocaine sprayed down the endotracheal tube attenuates the airway-circulatory reflexes by local anesthesia during emergence and extubation.

Anesthesia & Analgesia

,

96

, 293-297.

Klemola

, U.,

Saaenivaara

, L.,

Yrjola

, H. (1988). Post-operative sore throat: effect of lignocaine jelly and spray with endotracheal intubation.

European Journal of

Anaesthesiology

,

5

, 391-399.

Minogue, S. C., Ralph, J., &

Lampa

, M. J. (2004). Laryngotracheal

topicalization

with lidocaine before intubation decreases the incidence of coughing on emergence from general anesthesia.

Anesthesia & Analgesia

,

99

, 1253-1257.

Takekawa

, K., Yoshimi, S., & Kinoshita, Y. (

20

06). Effects of intravenous lidocaine prior to intubation on postoperative airway symptoms.

Journal of Anesthesia

, 20, 44-47.

Uehira, A., Tanaka, A.,

Mitsugu

, O., Sato, T. (1981). Obstruction of an endotracheal tube by lidocaine jelly.

Anesthesiology

,

55

, 598-599.

Youngberg, J. A., Graybar, G., Hutchings, D. (1983). Comparison of intravenous and topical lidocaine in attenuating the cardiovascular responses to endotracheal intubation.

Southern Medical Journal

,

76, No. 9

, 1122-1124.Slide21

Thank you for your time