Lidocaine and the Prevention of Emergence Phenomena Ian Lynch & Daniel Parker Gonzaga University Providence Sacred Heart Medical Center March 20, 2014 Ian

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 Ian Our motivation for our master thesis came from the wide variety of EP treatment modalities that we were exposed to in clinical practice. We have seen practioners use IV lidocaine at the beginning of a case, at the end, LTA’s, lidocaine jelly or ointment on the cough. So we wanted to trying to find evidence based decision regarding the efficacy of current treatment modalities.

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 Ian

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 Dan In addition to the literature review. We wanted to see what practioners in other places were doing since we know what is going on here at sacred heart.

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? Dan Our first two questions guided our survey questions The last two research questions helped define and order our literature review.

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) Dan Bullet 2: This direct contact with fragile tracheal mucosa is associated with the cough reflex (Fegan et al., 2000), mucosal irritation (Combes, 2001), and intubation trauma (Navarro, 1997) Bullet 3: IV narcotics, sedation, and extubation in a deep plane of anesthesia are also used. Concerns with these techniques included delayed emergence and obstruction or aspiration of an unprotected airway (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, Bedford, Weaver, and Colohan, 1981) Ian IV: Takekawa, Yoshimi, and Kinoshita (2006) found that among 80 ASA 1 and 2 patients undergoing general anesthesia IV lidocaine prior to intubation decreases the incidence and severity of sore throat and cough postoperatively compared to controlThe precise mechanism remains unknown. A possible mechanism could be the prevention of nociception and subsequent chronic pain. IV lidocaine suppresses sensory C and A delta afferent airway fibers. This may reduce the release of neuropeptides and secondary neuronal change (Takekawa, Yoshimi, & Kinoshita, 2006). Youngberg, Graybar, and Hutchings (1983) found that neither IV nor LTA completely attenuated cardiovascular responses to endotracheal intubation in 16 randomly assigned general surgical patients. But found that IV lidocaine 100 mg may be superior to LTA lidocaine 160 mg administered 90 seconds prior to intubation with significant (P <0.05) increase in heart rate lasting four minutes in IV lidocaine group compared to six minutes in the LTA lidocaine group. LTA: In 50 ASA I and II elective gynecological surgical patient’s requiring surgery of less than two hours’ time Minogue, Ralph, and Martin (2004) found in their double-blind, placebo-controlled, randomized trial that LTA lidocaine 160 mg, administered pre-intubation, decreased the incidence of cough by 26% prior to extubation compared to saline spray control Lidocaine spray: Hara and Maruyama (2005) hypothesized that additives contained in lidocaine products had a significant influence on postoperative sore throat and hoarseness. In this study the spray used contained l-menthol, ethanol, saccharin, sodium and macrogolum as additives in an alkalized solvent of pH 9.0-9.2. L-menthol, ethanol, and alkaline solutions can irritate mucosa. Lidocaine jelly/ointment: Uehira, Tanaka, Mitsugu, Oda, and Sato (1981) After experiencing a case of complete ET obstruction with lidocaine jelly Uehira, Tanaka, Mitsugu, Oda, and Sato (1981) compared five ET tubes covered with jelly and five ET tubes covered with lidocaine ointment. The ET tubes were exposed to 4 liters per minute of 60% N2O and 40% O2. After one hour, a consistent sheet like film on the inner surface of the ET tube was found with jelly. The same tubes covered with lidocaine ointment did not have any coating after seven hour

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 Ian LITA: Daichun et al. conclude that the administration of four percent lidocaine, 30 minutes prior to extubation results in the highest plasma concentration of lidocaine as well and a significant reduction in ETT induced coughing during emergence. They also found that this technique allowed patients to be awake and following commands without coughing prior to extubation enabling the anesthetic provider a safer extubation for difficult airway, full stomach, and GERD patients

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) Ian Lidocaine sprayed down the tube: Comparing lidocaine down ETTs to control, the number of coughs decreased and was clinically significant P <0.01. IV lidocaine versus control did not significantly decrease cough at emergence.

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 Dan 1: Time: Fagan et al., found that a period of 60 minutes or longer of having an ETT filled with alkalized lidocaine in place, is required to have any noticeable decrease in cough post extubation. Addition of Sodium Bicarbonate: Matias found that the addition of bicarbonate into a lidocaine solution increased the diffusion of said lidocaine across the ETTC by 63-fold. (Matias, 1995) Lidocaine Concentration: It appears that with low doses of lidocaine, even as low as 40 mg, with the addition of bicarbonate, showed better outcomes with EP when compared to higher dose, non-alkalinized solutions (Estebe et al, 2005). Efficacy and Safety: Two alkalized lidocaine groups showed significant reductions in sore throat during the 24-hour postoperative period over the air filled control group. They also had greater tube tolerance at the end of the case as well as no depression of the swallowing reflex or incidence of laryngospasm. However, there was no difference between the two alkalinized L-HCL groups (Estebe et al, 2005). Results of this study show that the safer concentration of sodium bicarbonate is equally as effective as using the high dose 8.4%. Following the Herndersson-Haaselbach equation, the addition of NaHCO3 to L-HCL alkalizes the lidocaine solution from a pH of 6.7 up to a pH of 8.3 after adding 8.4% sodium bicarbonate solution. This information allows the use of smaller doses of lidocaine, (20-40mg), to be used with equal efficacy of higher doses absent NaHCO3 (Dollo, Estebe, Corre, Cevanne, Ecoffey, and Verge, 2001).

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 Ian

Findings Dan Practices varied between respondents. Results showed that 210 (94.6%) of respondents never use an LITA, 207 (92%) of respondents never used alkalized lidocaine, 166 (73.1%) of respondents never used lidocaine ointment, and 133 (57.8%) never used lidocaine jelly on the ETTC. In contrast, the more commonly used techniques to prevent EP included: 129 (50.8%) always or often used IV narcotics to prevent EP, 76 (29.9%) always or often used other techniques including propofol, deep extubation for EP prevention, and 67 (26.4%) of respondents always or often use an LTA during induction to prevent EP (

Findings Dan IV narcotics with results showing that 112 (44.1%) of respondents believe it to be very or most effective in its prevention of EP, while 28 (11%) of respondents found this technique to be least of not very effective. Of those that use the LTA, 86 (33.9%), thought that it was the most or very effective technique for preventing EP while 44 (17.3%) perceived it as not very or least effective. The data showed that 52 (20.5%) of the respondents selected IV lidocaine as very or most effective, but 65 (25.6%) perceived IV lidocaine as least or not very effective. Meanwhile, lidocaine jelly was perceived as very or most effective by only 29 (11.4%) of respondents. In contrast, lidocaine jelly was thought to be least or not very effective by 84 (33.7%) of respondents

Findings Dan LTA lidocaine with 178 (70.1%) respondents selecting LTA as being the safest of very safe treatment modality, with only 11 (4.3%) of the respondents reporting LTA lidocaine to be least or not very safe. Next, 169 (66.5%) of the respondents reported IV lidocaine to be the safest or very safe treatment for preventing EP, and only 5 (2.1%) selected IV lidocaine as being least or not very safe. IV narcotics were reported as safest or very safe by 148(58.3%) or survey respondents, while 9(3.5%) of respondents reported IV narcotics as least or not very safe. Of the 254 respondents, 110 (43.3%) reported lidocaine jelly as being safest or very safe, with 37 (14.6%) reporting it to be least or not very safe. Furthermore, lidocaine ointment was reported as being the safest for very safe by 83(32.7%) of respondents. Meanwhile, 44 (17.3%) of respondents reported lidocaine jelly to be the least or not very safe. LITA was selected as the safest or very safe by 52 (20.5%) of survey respondents with only 15 (5.9%) selecting least or not very safe. Finally, alkalized lidocaine was reported as being the safest or very safe by 39 (15.4%) and least or not very safe by 27 (10.6%) (Figure 4).

Findings Dan Of the 254 respondents, 105 (43.8%) reported being unfamiliar or have never heard of lidocaine filled endotracheal tube cuffs. 87 (36.3%) had heard of the technique. 40 (16.7%) had read about it. 32 (13.3%) reported that they had learned the technique but are not currently using it. 17 (17.1%) had seen the technique in use. Thirteen (15.4%) of respondents reported that they are currently using the technique.

Findings n=9 Ian

Findings Ian

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 Ian As educators, it is our hope that this technique becomes more widespread and the benefits are seen for both the anesthesia provider as well as the patient population

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.

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