Topical Lidocaine as Adjunct to Intubation Without Muscle Relaxant in Pediatric Patients

This is the authors' abstract. We don't add key points for this paper.

We read with great interest the results of the survey of the Society of Pediatric Anesthesiology's members concerning tracheal intubation using inhaled anesthetic without muscle relaxant (IAWMR) (1). Though we have no doubt of the veracity of the results, we wonder if they may be somewhat misleading in that the use of other adjuncts, specifically topical lidocaine, was not addressed. Thus, the results could be interpreted as a significant portion of the membership of the Society for Pediatric Anesthesia use only a volatile anesthetic to intubate the trachea of their healthy, fasted pediatric patients undergoing elective procedures. We would like to emphasize that adjuncts, other than muscle relaxants, may have been employed by an indeterminate number of the respondents. This would represent a different technique, as other agents may have considerable influence on the depth of anesthesia, the dose of inhalation anesthetic required, and intubating conditions. We believe that the use of additional agents in IAWMR is important and needs to be noted to better reflect the clinical method of this widely used technique. In our pediatric anesthesia group, composed of three generations of anesthesiologists trained in five different institutions, we all teach IAWMR (with and without an IV) but add topical lidocaine before tracheal intubation in the following manner: direct laryngoscopy is performed; 4 mg/kg (up to 2 mL) of 2% lidocaine is sprayed onto the glottic area; mask ventilation for 3 to 4 breaths; repeat direct laryngoscopy for tracheal intubation. With the use of topical lidocaine, we have found that IAWMR can be performed at smaller levels of a volatile anesthetic. In addition, our clinical experience is that obstruction, laryngospasm, and desaturation after intubation rarely occur with IAWMR with topical lidocaine. Therefore, we believe that practitioners who attempt IAWMR should understand that additional drugs, particularly topical lidocaine, may be valuable adjuncts and should be considered. Amr Abouleish MD, MBA Jeffrey Berman MD Nhung Chai Nguyen MD Samson Otuwa MD Lee Woodson MD, PhD James Mayhew MD