IV lidocaine for wake ups

[DrDre']

Howdy all,
I have been experimenting with IV lidocaine at the end of cases to hopefully have a nice, mellow baby bird wakeup. It seems to be totally hit or miss...

Your practice? dose, timing, in combo with...

Thanks!

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[dhb]

I suppose your doing a volatile based anesthetic? coincidentally i looked briefly into this yesterday because i had the feeling that propofol blunts the reponse to the ETT kind of like midaz.
And the literature says the same: incidence of coughing/bucking 50-80% with volatiles 5-10% with TIVA.

I think that the hit or miss is more statistical (incidence of bucking 50%) than any kind of effect of lidocaine. I don't buy the blunting the reaction to airway manipulation theory since i always mix lidocaine with propofol at induction and i've never seen it happen.

quick search and here it is: (another myth busted right here on SDN)

"Lidocaine effects on the laryngeal chemoreflex, mechanoreflex, and afferent electrical stimulation reflex.McCulloch TM, Flint PW, Richardson MA, Bishop MJ.
Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle.

The use of lidocaine hydrochloride as either a topical or intravenous agent has become a common practice for minimizing laryngospasm and the reflex cardiovascular effects resulting from upper airway manipulation. The efficacy and mechanism of action of lidocaine for this purpose remain unclear. We evaluated the effect of lidocaine on the laryngeal chemoreflex (LCR), mechanoreflex (LMR), and superior laryngeal nerve electrical stimulation adductor reflex (SLN-ESAR) in piglets. Cardiopulmonary responses were used to assess LCR and LMR. Latency following SLN stimulation was used to assess SLN-ESAR. Intravenous lidocaine hydrochloride at 3 mg/kg produced no suppression of the LCR, LMR, or latency (SLN-ESAR onset latency before lidocaine 11.7 +/- 0.7 milliseconds, after lidocaine 12.2 +/- 0.5 milliseconds; peak latency before lidocaine 13.2 +/- 0.2 milliseconds, after lidocaine 13.4 +/- 0.4 milliseconds). Topically applied lidocaine at the same dose eliminated both LCR and LMR responses in all animals, with return of reflex responses 15 minutes after application. No effect on the SLN-ESAR was seen with application of topical lidocaine. This study supports topical lidocaine as a suppressant of laryngeal mucosal neuroreceptors without central neural reflex effects. Intravenous lidocaine did not affect peripheral neuroreceptors, nor did it significantly affect the latency of the SLN-ESAR neural reflex arc. Intravenous and topical lidocaine differ in mechanism of action and efficacy with regard to modulation of reflex effects induced by laryngeal stimulation."

 

[Planktonmd]

What Lidocaine does is simply deepen your anesthetic for a short period of time that allows you to pull the tube out while the patient is more anesthetized and as a result not coughing too much.
You can do that with any other agent: Narcotic, Hypnotic, Sedative and even more inhaled agent!

 

[New2Midwest]

If you want great smooth wake-ups consistently with each case, I recommend dexmedetomidine boluses (typically boluses of 8 mcg at a time). Typically, even for the crazy wake up folks (ie crazy pre-operative personalities, drug addicts, melodramatic folks), a total of 24-32 mcg total over the 15-20 minutes prior to wake up does the trick. They usually just open their eyes to voice; I ask if they want the tube out; they nod their head yes and I take it out. It's cool-because when you call their name the BIS value goes from 50 to 90 in about 15 seconds. There is usually no coughing or bucking on the tube either. I find that this technique consistently works great. Minimal resp. depression; good sedation; good titration as well.

 

[dfk]

If you want great smooth wake-ups consistently with each case, I recommend dexmedetomidine boluses (typically boluses of 8 mcg at a time). Typically, even for the crazy wake up folks (ie crazy pre-operative personalities, drug addicts, melodramatic folks), a total of 24-32 mcg total over the 15-20 minutes prior to wake up does the trick. They usually just open their eyes to voice; I ask if they want the tube out; they nod their head yes and I take it out. It's cool-because when you call their name the BIS value goes from 50 to 90 in about 15 seconds. There is usually no coughing or bucking on the tube either. I find that this technique consistently works great. Minimal resp. depression; good sedation; good titration as well.

sounds great, but doesn't this get expensive?

 

[dhb]

Pull the tube deep; works every time (just don't tell maceo 😉 )

 

[Mofeen]

I like about 3-5 mL of 4% Lidocaine down the ETT about 10 min before extubation. At my institution we also have the Sheridan LITA tubes http://www.metropolitanmedical.com/prod/SHELITCuf_1.htm to make it even easier.

 

[periopdoc]

I have been experimenting with IV lidocaine at the end of cases to hopefully have a nice, mellow baby bird wakeup. It seems to be totally hit or miss...

Your practice? dose, timing, in combo with...

My thoughts...

IV Lido is just another anesthetic agent...

but it has a much narrower therapeutic index than our other IV anesthetic agents.


- pod

 

[BLADEMDA]

My thoughts...

IV Lido is just another IV anesthetic agent...

but it has a much narrower therapeutic index than our other IV anesthetic agents.


- pod

If you must give another agent for a smooth wake-up (which is not usually needed) then consider low dose propofol. Propofol is cheap and very effective for blunting laryngeal reflexes. In addition, you may have 50 mg left-over from induction in your syring so net cost is zero. You RARELY need to give more than 0.5 mg/kg to block larygeal reflexes so low dose works well and usually allows spontaneous respirations to continue or return quickly.

While I don't believe a single small dose of propofol is a good anti-emetic (tried this for many years without success) some research suggest it may reduce the incidence of postoperative nausea in the PACU.

 

[Noyac]

If you must give another agent for a smooth wake-up (which is not usually needed) then consider low dose propofol. Propofol is cheap and very effective for blunting laryngeal reflexes. In addition, you may have 50 mg left-over from induction in your syring so net cost is zero. You RARELY need to give more than 0.5 mg/kg to block larygeal reflexes so low dose works well and usually allows spontaneous respirations to continue or return quickly.

While I don't believe a single small dose of propofol is a good anti-emetic (tried this for many years without success) some research suggest it may reduce the incidence of postoperative nausea in the PACU.

I agree with the prop for wake up. But I also believe that it "helps" with nausea as well. Have you ever tried it in the recovery room on an awake pt with nausea? It usually works well enough to get the pt moving to the floor or home.

 

[Noyac]

I like about 3-5 mL of 4% Lidocaine down the ETT about 10 min before extubation. At my institution we also have the Sheridan LITA tubes http://www.metropolitanmedical.com/prod/SHELITCuf_1.htm to make it even easier.

The Sheridan tubes are nice. I use them for carotids and Cervical fusions usually. They prevent coughing almost every time. But I also extubate these cases deep most of the time.

Has anyone tried filling the cuff of a regular ETT with 4% lido? I've heard of it but never done it.

 

[ProRealDoc]

I agree with the prop for wake up. But I also believe that it "helps" with nausea as well. Have you ever tried it in the recovery room on an awake pt with nausea? It usually works well enough to get the pt moving to the floor or home.

Works like magic everytime. Use it in PACU quite a bit.

 

[periopdoc]

Has anyone tried filling the cuff of a regular ETT with 4% lido? I've heard of it but never done it.

I use this technique frequently for longer cases >4h where I plan to extubate at the end of the case. I assume that the benefit would be negligible on shorter cases, but I haven't tried it and I haven't looked for any published data on short cases.

The literature is clear that alkalinization improves diffusion of the lidocaine through the ETT cuff. I use the 1cc of bicarb per 5cc of 4% lido rule to make my solution up. Then I fill the cuff to occlude the cuff leak.

Jean-Pierre Estebe's group has published on a lower concentration lidocaine technique using 40mg of 2% lidocaine topped off with whatever volume of bicarb is necessary to occlude the cuff leak. I am not sure if they are really advocating this technique or simply trying to define the lower limit of what is possible. I personally don't see a major issue with the higher plasma levels of lido when utilizing the 4%.

A few issues to keep in mind.

1) As with any fluid filled ETT cuff, be meticulous about checking for a cuff leak. It is easier to inadvertently apply excessive pressure to the tracheal mucosa with a fluid filled cuff.

2) It can be hard to tell if the balloon is completely deflated by feel alone. Keep a measurement of how much fluid you put in so you know how much fluid to remove at the end. I don't know if a removing a tube with a partially inflated cuff would actually cause any additional trauma, but it sounds like a bad idea.

3) If you decide not to extubate, it is probably a good idea to remove the fluid from the cuff and reinflate with air. It really throws the RT's off when they suck fluid out of the cuff and it could potentially cause a problem if they do not know how much fluid you started with.

- pod