Abstract
Background Airway topicalisation with local anaesthetic (LA) is common in paediatric anaesthesia to facilitate endoscopic airway procedures, reduce perioperative complications and provide analgesia. Topicalisation has a risk of LA toxicity and aspiration, however, guidance on LA dosing and fasting duration is limited. A review of literature and local practice was done to standardise nil-by-mouth time and advise on LA dosing via a SOP.
Methods Records of patients who underwent MLB at GOSH between September-December 2021 were reviewed. LA dose, fasting instructions, time nil-by-mouth and complications were recorded. A departmental survey was also undertaken to identify individual practice. Based on findings a SOP was introduced in November 2022 and a re-audit completed In July 2023.
Results 224 records were reviewed, with no recorded episodes of LA toxicity, aspiration or intraoperative complications. 1% and or 4% lidocaine were used in all cases with 2-3mg/kg (0.37-5.7) used in 72% of cases. Fasting instructions were undocumented in 23% of cases. Fasting times varied from 20 minutes-3h15, with 75% of children fasted over 1hr postoperatively. 25 doctors (92% Consultants) completed the survey. No episodes of aspiration were recorded. 3mg/kg was the most commonly used LA dose (52%) and fasting times varied significantly.
Discussion Current evidence supports the safe dose of 5mg/kg, with LA toxicity risk highest in neonates and infants. Aspiration risk is low and 1 hour fasting has been suggested following a literature review.
Conclusion A SOP was created to maintain safe practice, improve patient comfort by minimising fasting, and provide clarity to anaesthetists and recovery staff. Key points: children should be fasted for 1 hour post-topicalisation, a dose of 5mg/kg lidocaine is safe, volume and concentration of lidocaine is at the discretion of the anaesthetist. This has improved documentation and reduced the proportion of children fasted for over 1 hr.
