Comment on ‘Local anaesthetic documentation: from maximum dose to cumulative dose reconciliation’

We read with interest Featherstone et al.'s quality improvement report on local anaesthetic documentation [1]. Completion of six Plan-Do-Study-Act cycles over 10 months is commendable, and the results highlight an implementation lesson that education and a nomogram alone did not produce sustained change, whereas embedding the process into the theatre sign-in and anaesthetic record did. One point warrants clarification. The methods state that the nomogram calculated maximum dose using lean body weight, whereas Appendix S1 appears to label the main dosing table as actual body weight; only the airway topicalisation section specifies lean body weight [1]. This distinction matters at extremes of body weight and resources vary in using actual, ideal or lean body weight [2]. Weight bands, rounding down and capped ranges are conservative, but clarification would aid safe replication. We welcome the separate airway topicalisation prompt. Awake tracheal intubation differs from wound infiltration or peripheral nerve block, and guidance uses a distinct lidocaine dosing framework [3]. Such prompts may help clinicians apply the correct framework, without implying routine use of the maximum dose. The next step is cumulative dose reconciliation. Future cycles could examine total administered dose; threshold exceedance; discrepancies between anaesthetic, surgical and nursing records; adjustment for multiple agents; and recent exposure before boluses or infusions [4]. The redesigned sticker supports this shared team process by separating anaesthetic, surgical and total dose fields. Electronic records could calculate limits, convert concentration and volume to milligrams, sum incremental doses and alert when the dose exceeds thresholds. Clarifying the weight scalar and extending the intervention to cumulative dose reconciliation would strengthen its value.