Adding intranasal lidocaine to midazolam may benefit children undergoing procedural sedation

Article Outline

• Question
• Design
• Setting
• Participants
• Intervention
• Outcomes
• Main Results
• Conclusions
• Commentary
• Reference
• Copyright

Chiaretti A, Barone G, Rigante D, Ruggiero A, Pierri F, Barbi E, et al. Intranasal lidocaine and midazolam for procedural sedation in children. Arch Dis Child 2011;96:160-3.

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Question 

Among children who undergoing minor painful or diagnostic procedures, is the addition of intranasal lidocaine spray to intranasal midazolam (INM) safe and efficacious?

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Design 

Prospective, observational study.

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Setting 

Single hospital and emergency department in Rome, Italy.

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Participants 

46 children, aged 5-50 months, who were considered uncooperative or anxious prior to their procedure.

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Intervention 

INM (0.5 mg/kg) via a mucosal atomizer device. To avoid any nasal discomfort a puff of lidocaine spray (10 mg/puff) was administered before INM.

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Outcomes 

The child's degree of sedation (using a modified Ramsay sedation scale) and the parents' and doctors' opinions on the efficacy of the sedation (using a questionnaire).

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Main Results 

The degree of sedation achieved by INM enabled all procedures to be completed without additional drugs. Premedication with lidocaine spray prevented any nasal discomfort related to the INM. The mean duration of sedation was 23.1 min. The depth of sedation was 1 on the modified Ramsay scale. The questionnaire revealed high levels of satisfaction by both doctors and parents. Sedation start and end times were significantly correlated with age only. No side effects were recorded in the cohort of children studied.

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Conclusions 

This study has shown that the combined use of lidocaine spray and atomized INM appears to be a safe and effective method to achieve short-term sedation in children to facilitate medical care and procedures.

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Commentary 

Previous studies have shown INM to be a safe and effective medication for minor procedures in young children.¹ Frequent complaints of this regimen include a burning sensation and a bitter taste in the mouth. The present study shows that intranasal lidocaine given prior to INM can eliminate these unpleasant side effects in all patients, optimizing patient, parent, and doctor satisfaction. Although the authors did attempt to limit biases, the unblinded nature of the study leaves room to doubt the effects of the intervention due to expectation bias. As the authors note, a larger, double-blind, randomized study would be helpful to confirm the findings that are shown in this study. Such a study could also provide insight into determining the impact, if any, that the type of minor procedure performed or the dose of lidocaine may have on the results. Overall, these findings are promising and show that intranasal lidocaine may be a useful adjunct to INM.

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Reference 

1. Lane RD, Schunk JE. Atomized intranasal midazolam use for minor procedures in the pediatric emergency department. Pediatr Emerg Care. 2008;24:300–303
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