Lidocaine and the
Prevention of
Emergence
Phenomena
Ian Lynch & Daniel Parker
Gonzaga University
Providence Sacred Heart Medical Center
March 20, 2014
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 EP
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
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
room
Guiding Research Questions
1. What are surveyed CRNAs doing to
prevent EP?
2. To what degree are practitioners familiar
with the use of lidocaine filled
endotracheal tube cuff (ETTC)?
3. How does an ETTC filled with lidocaine
compare to other treatment modalities?
4. What are the risks and benefits of various
treatment modalities for EP?
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)
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,
Weaver, and Colohan, 1981)
Bedford,
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 emergence
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)
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 safer
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 participate
Findings
Findings
Findings
Findings
Findings n=9
Findings
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 pressure
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.
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. (2006). 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.
Thank you for your time