Topical Administration Of Lidocaine Research Articles

Comparing topical administration of lidocaine alone and in combination with alfentanil in children undergoing bronchoscopy

Introduction:Airway surgery and endoscopy in pediatric patients are always associated with challenges in anesthesia management. Deep anesthesia is required for preventing patient bucking during the procedure but patient breath should be maintained; in this regard, a combination of general and topical anesthesia can be beneficial. There is also evidence of the peripheral effects of opioids. The main objective of this study is to compare using lidocaine topically alone and combined with alfentanil opioids with respect to the central effects of opioids.Methods:In this study, 40 ASA class I and II children, aged 1–6 years, who were candidates for flexible diagnostic bronchoscopy were divided into two groups through block randomization using the random number table after obtaining parents' consent in complete health conditions. In this clinical trial, for collecting the data a special data collection form was used at the bedside of patients undergoing bronchoscopy at Pediatric Medical Center in 2017. Data including demographic information (age, weight, gender), duration of anesthesia, blood pressure before and after drug administration, duration of bronchoscopy, and recovery time were recorded in a form.Findings:In terms of demographic variables, there were not any significant differences between the two studied groups, indicating that the groups were matched and randomized appropriately. Although there were not any significant differences between the two groups of using lidocaine alone and in combination with alfentanil in other variables, in the recovery time a significant difference was observed between the two groups, with a mean of 13.05 min in the lidocaine group and 18.75 min in the lidocaine combined with alfentanil group.Conclusion:Topical administration of opioid with lidocaine through bronchoscopy had no impact on blood pressure, heart rate, anesthesia duration, and the frequency of perioperative complications.

Effects of Lidocaine Oropharyngeal Spray Applied Before Endotracheal Intubation on QT Dispersion in Patients Undergoing Coronary Artery Bypass Grafting: A Prospective Randomized Controlled Study.

ObjectiveTo investigate the effects of lidocaine oropharyngeal spray applied before endotracheal intubation on hemodynamic responses and electrocardiographic parameters in patients undergoing coronary artery bypass grafting.MethodsA total of 60 patients who underwent coronary artery bypass grafting surgery were included in this prospective randomized controlled study. Patients were randomly divided into two groups, the topical lidocaine group (administration of 10% lidocaine oropharyngeal spray, five minutes before laryngoscopy and endotracheal intubation) and the control group. Both groups were compared with each other in terms of main hemodynamic parameters including mean arterial pressure and heart rate, as well as P and QT wave dispersion durations, before and after endotracheal intubation.ResultsThe groups were similar in terms of age, gender, and other demographics and basic clinical characteristics. There was a statistically significant difference between the groups in terms of QT dispersion durations after laryngoscopy and endotracheal intubation. The increase in QT dispersion duration was not statistically significant in the topical lidocaine group, whereas the increase in QT dispersion duration was statistically significant in the control group. When the groups were compared in terms of P wave dispersion durations, there were significant decreases in both groups, but there was no significant difference between the groups.ConclusionOur study revealed that the topical lidocaine administration before endotracheal intubation prevented increase of QT dispersion duration in patients undergoing coronary artery bypass grafting.Trial RegistrationNCT03304431

Acquired Methemoglobinemia Associated with Topical Lidocaine Administration: A Case Report.

A 55-year-old male was admitted to the hospital with pneumonia. During an intubation procedure, the patient received an application of endobronchial lidocaine (4% gel). Within 2 h of intubation, the patient developed worsening hypoxia, and investigation of arterial blood gasses revealed a pH of 7.21, carbon dioxide partial pressure (PaCO2) of 3.3 kPa, oxygen partial pressure (PaO2) of 55.1 kPa, and measured oxygen saturation of 49%. Co-oximetry of this sample returned a methemoglobin level of 53%. Intravenous methylthioninium chloride (1% solution at 1 mg/kg) was delivered, and subsequent arterial blood gasses, at 30 min and 1 h post administration, showed methemoglobin levels of 12 and 9%, respectively, with return of oxygen saturation to > 90%.

Topical lidocaine inhibits spasm during colonoscopy: a double-blind, randomized controlled trial (with video).

Background and study aims Topical peppermint oil prevents intestinal spasm, but can cause rebound spasm. Lidocaine hydrochloride, a local anesthetic, may work as an antispasmodic by blocking Na + channels. The aim of this study was to investigate the effect of topical lidocaine on the inhibition of colonic spasm during colonoscopy, compared with peppermint oil. Patients and methods A randomized, controlled double-blind trial was conducted in an academic endoscopy unit. Patients requiring endoscopic resection were randomly allocated to colonoscopy with topical administration of lidocaine (n = 30) or peppermint oil (n = 30). Similar vials containing different solutions were randomly numbered. Allocation was made based on the vial number. The solution used and the vial number were not revealed during the study. Two endoscopists performed all procedures using midazolam, without anticholinergic agents. When a pre-selected lesion was identified, the solution in the assigned vial was dispersed and the bowel observed for 5 minutes. The primary endpoint was the duration of spasm inhibition, and a secondary endpoint was the occurrence of rebound spasm stronger than before dispersion. Results There were no significant differences in patient demographics. Spasm was inhibited in almost all patients in both groups, with a similar median duration (lidocaine 227 sec vs. peppermint 212.5 sec, P = 0.508). In contrast, rebound spasm occurred less frequently in the lidocaine group (lidocaine 7 % vs. peppermint 47 %, P = 0.001). There were no adverse events or symptoms associated with administration of the solutions. Conclusions The inhibitory effect of lidocaine is not superior to peppermint oil. However, lidocaine significantly decreases the frequency of rebound spasms.

Topical Lidocaine Does Not Exaggerate Laryngomalacia in Infants During Flexible Bronchoscopy Under Propofol Anesthesia.

Topical lidocaine has been found to result in overestimation of the severity of laryngomalacia in infants undergoing flexible bronchoscopy under conscious sedation with midazolam and nalbuphine. This effect has never been confirmed and may depend on the level of sedation and the drugs used. We assessed the effect of topical lidocaine on laryngomalacia in infants undergoing flexible bronchoscopy under general anesthesia with propofol. Thirteen infants with congenital stridor referred to diagnostic flexible video-bronchoscopy were studied under propofol anesthesia before and 3 minutes after topical lidocaine administration to the larynx at a dose of 3 mg/kg body weight. Laryngomalacia was scored using 60 seconds video recordings of the larynx before and after lidocaine administration in random order by 2 independent blinded observers using the previously described arytenoid score (AS), epiglottis score (ES), and the total score (TS=AS+ES). No significant differences in AS, ES, and laryngomalacia score were found between the prelidocaine and postlidocaine assessments by the 2 raters. The intraclass correlation coefficients were 0.995 (95% confidence interval, 0.986-0.998) and 0.975 (0.930-0.991) and 0.989 (0.971-996) for AS, ES, and TS, respectively. The assessment of laryngomalacia is not affected by topical lidocaine under propofol anesthesia. The lidocaine effect on laryngomalacia may vary depending on the medication regime used and the depth of procedural sedation.

Site-directed topical lidocaine spray attenuates perioperative respiratory adverse events in children undergoing elective surgery

BackgroundPerioperative respiratory adverse events (PRAEs) are a major cause of morbidity and mortality associated with pediatric anesthesia. Topical lidocaine administration reduces risk of PRAE in children undergoing elective endotracheal intubation. However, definitive evidence of its efficacy remains elusive, due, in part, to the wide variability in the methodology for spraying topical lidocaine. In this randomized controlled double-blind clinical trial, we sought to evaluate the effect of site-directed topical airway lidocaine, sprayed directly onto supraglottic, glottis, and subglottic areas, on the incidence of PRAE. MethodsThe study population consisted of 322 children (age range, 6 mo-12 y), who were scheduled for an elective surgical procedure under general anesthesia with endotracheal intubation. Patients were randomly assigned to receive topical spray of lidocaine (group L) or saline (group S) over the supraglottic, glottis and subglottic areas under direct vision before tracheal intubation. Incidence of PRAE and time to extubation was recorded. ResultsThere were no statistically significant intergroup differences with regard to baseline demographics, patient characteristics, and surgical parameters. Group L was associated with a significantly lower incidence of PRAE as compared with group S (12.80% versus 38.13%, respectively; P < 0.001). Similarly, the incidence of laryngospasm (1.7% versus 8.1%; P = 0.01), excessive coughing (4.3% versus 13.2%; P = 0.005), and oxygen desaturation <95% (6.8% versus 16.9%; P = 0.005), respectively, was significantly lower in group L. However, time to extubation was longer in group L as compared with that in group S (18.6 ± 7.7 min versus 21.3 ± 8.9 min; P = 0.03). ConclusionsSite-directed topical spray of lidocaine over supraglottic, glottis, and subglottic areas before tracheal intubation significantly reduced the incidence of PRAE and a prolongation of extubation time in children.

Microneedle Integrated Transdermal Patch for Fast Onset and Sustained Delivery of Lidocaine

Lidocaine as an analgesic is of particular interest in both acute and chronic pain conditions and is used via injections or transdermal patches. While injections are associated with problems such as patient incompliance, topical administration of lidocaine using patches is less efficient due to variability of drug absorption among individuals, slower drug permeation through the skin, and hence a resultant undesirable delay in analgesic effects. To address this clinical problem, we developed a microneedle integrated transdermal patch (MITP), using a photolithography based process, in which microneedles create micrometer-sized channels in the skin to deliver lidocaine rapidly, while the reservoir patch holding the bulk of the drug enables higher drug loading and carries on to release the drug for prolonged periods. We demonstrated a new approach of drug delivery using microneedles, where drugs diffuse out of microneedles through the porous channels left by dissolving drug particles. MITP was shown to be able to encapsulate up to 70 mg of lidocaine. In vitro permeation through rat skin demonstrated that MITP delivered a significantly higher amount of lidocaine than a commercial patch and with a faster onset of drug permeation.

Preparation and Characterization of Lidocaine Double Layer Buccal Tablet Using Mucoadhesive Carbopol® Polymers

The present study was intended to develop a new oral mucosal dosage form with a view of solving problems of the topical administration of Lidocaine, a local anesthetic drug, in the oral cavity. The drug was formulated as sustained release mucoadhesive bilayered tablets using mucoadhesive polymers. The first layer, consisting of a drug impermeable backing, was prepared by compression of Kollidon SR, Mg-stearate, Aerosil and talc blend in a hydrolic press at 5 ton pressure for 5 seconds. The second layer, responsible for buccal drug delivery and tablet retention on the mucosa was obtained by compression of a mixture of drug, mucoadhesive polymer and cellulose derivative for 1 min at 5 ton pressure. The tablets were evaluated in terms of swelling and water uptake and in vivo mucoadhesive performance was performed with nonmedicated tablets. In vitro drug release studies were also carried out containing fixed amount of Lidocaine (50mg), different concentrations of mucoadhesive polymer (Carbopol 934P) and hydroxypropyl methyl cellulose (HPMC). Drug release was only 30.9% in 6 hours when Carbopol 934P was used alone and at a higher concentration (240mg). Release was faster when lower concentration of polymer was used. When used in combination with HPMC, drug release was slower. In vivo mucoadhesive performance with nonmedicated tablets showed very good adherence to buccal mucosa for 6 hours and no signs of irritation was reported. Moreover, it adheres well to the gum, is not washed away by salivary fluid and is simple to apply, which indicates a better patient compliance. DOI: http://dx.doi.org/10.3329/dujps.v10i1.10012 DUJPS 2011; 10(1): 29-34

A 70-year-old man with pruritic plaques

The use of IPL has also been studied as a treatment option for patients with facial lentigines, such as those seen in PJS. Remington et al treated a single PJS patient with IPL (47 J/cm, 3.2 msec pulse duration, 591-1200 nm) after the administration of topical lidocaine and oral sedation. There was almost complete clearance of perioral, periorbital, and nasal areas after only one treatment, but 12 treatments on separate occasions were performed because of the patient’s pain intolerance. For this series, the recommended choices are: 6, e; 7, e; 8, e; 9, a; 10, a; and 11, b.

Lidocaine 2% jelly versus lidocaine 2%-sodium hyaluronate 0.3% drops in phacoemulsification surgery

Dear Editor, Lidocaine jelly has been used as a topical anesthetic in cataract surgery with satisfactory results [1, 2]. Its advantages, such as the avoidance of repeated corneal irrigation [3], and its disadvantages, such as the difficulty in applying the appropriate amount of lidocaine jelly [4], have occasionally been discussed in the literature. Interestingly enough, the preparations of lidocaine per se may present differences with respect to their actions or side-effects [5]. This randomized controlled trial compares two distinct modes of topical lidocaine administration in terms of efficacy (pain control) and conjunctival redness: (i) Lidocaine 2% jelly (Xylocaine, AstraZeneca), standardized amount of 1 ml (LJ group, n=73) and (ii) Lidocaine 2%-sodium hyaluronate 0.3% (Visthesia, Zeiss), 0.3 ml, i.e., one ampoule, (LSH group, n=77). The topical anesthetic was administered 10 min prior to the beginning of phacoemulsification (Alcon Series 20000 Legacy). The need for additional topical anesthetic was recorded in both groups. All procedures were performed by the same surgeon. No intracameral component was administered. After the completion of surgery, patients were asked to rate their pain on a visual analog scale (VAS, range: 0–10). In addition, the presence of conjunctival redness was independently assessed by two ophthalmologists (IPC and LP) 10 min after the administration of topical anesthesia (and evidently prior to the beginning of surgery). Statistical analysis was performed with STATA 8.0 statistical software (StataCorp, College Station, TX, USA). This study is in accordance with the Declaration of Helsinki and has been approved by the local ethics committee. Written informed consent was obtained from all patients. The authors declare no conflict of interest. The evaluated parameters, along with their statistical significance are presented in Table 1. The LSH group exhibited less intense pain than patients treated with lidocaine 2%. Interestingly enough, the percentage of redness was significantly higher in patients treated with LJ. Neither VAS score nor conjunctival redness was associated with gender or age in the treatment groups. The results remained practically unchanged after the exclusion of patients needing additional administration of topical anesthetic. The superiority of the LSH group in terms of pain was statistically significant; nevertheless, the magnitude of the difference in VAS ratings was small and both groups scored below 1/10 on average. Consequently, both protocols seem to guarantee a well-tolerated phacoemulsification procedure. In conclusion, the most striking finding of this study is the high incidence of conjunctival redness after the administration of topical LJ. This may imply a mild, temporary irritating effect of some constituents of the jelly, which has not been especially designed for the eye. Indeed, in the Product Monograph of a commonly used LJ (Xylocaine, AstraZeneca) [6], there is a clear warning to “avoid contact with eyes”; however, the use of LJ seems fairly established [1–4]. It should be stressed that the clinical significance of this effect on the conjunctiva remains rather elusive, as no major adverse general or eye-related outcomes became evident in our study. In any case, biochemical studies aiming I. P. Chatziralli (*) : L. Papazisis Department of Ophthalmology, Veroia General Hospital, Greece, 28, Papanastasiou Street, Athens, 17342, Greece e-mail: eirchat@yahoo.gr

Topical lidocaine and the effect on enoxaparin absorption in children: A pilot study

Enoxaparin, a low molecular weight heparin (LMWH), is frequently used for the prevention and treatment of thromboembolic complications in infants and children (Sutor et al., 2004 [1]). Injection pain and the fear and anxiety associated with needle phobia in the pediatric population are well documented. Best practice pediatric pain management standards of care recommend mitigating the child's pain experience whenever possible. The use of topical anesthetics such as liposomal-lidocaine 4% results in a rapid onset of anesthesia, minimal blanching, without vasoconstriction (Koh et al., 2004 [2]) or risk of methemoglobinemia. Topical lidocaine has been used to reduce the injection pain of enoxaparin, but there is no data available examining whether it will interfere with the absorption of LMWH. Objective To determine if the topical lidocaine, Maxilene, interferes with enoxaparin absorption as measured by peak anti-Xa levels. Methods Infants and children clinically prescribed enoxaparin were eligible for this study. Children in group 1 were pre-treated with Maxilene prior to enoxaparin injection on day 1 with no Maxilene pre-treatment on day 2. For group 2, the order was reversed. Peak anti-Xa levels were measured following each enoxaparin dose and were compared between the groups. Results 26 children of ages 14d-16 y (median 6.7 months) were enrolled. Anti-Xa levels following topical lidocaine administration were 0.070 U/mL (95%CI 0.025; 0.114) lower than without prior topical lidocaine administration. Anti-Xa levels on the second day were on average 0.013 U/mL (95%CI -0.066; 0.040) higher compared to day one regardless of the order of topical lidocaine administration. There were no reported incidences of local reactions such as redness, hives or blanching. Conclusions Topical lidocaine (Maxilene) administration before enoxaparin injection results in a small, clinically non-significant, reduction in anti-Xa levels.

Lidocaine lollipop as single-agent anesthesia in upper GI endoscopy

Conscious sedation is usually achieved during EGD by a combination of intravenous benzodiazepines and opiates; however, these have potential serious adverse effects. The addition of topical oropharyngeal anesthetics such as lidocaine may be useful. Recent data suggest that the administration of topical lidocaine by means of a lollipop is effective for endotracheal intubation and bronchoscopy. Our purpose was to evaluate the safety and efficacy of a lidocaine lollipop as single-agent anesthesia for EGD and to determine whether its use reduces the need for intravenous sedatives and analgesics. Single-blinded, randomized, prospective study. University hospital. 50 patients undergoing diagnostic EGD. Patients were randomized to either lidocaine lollipop or lidocaine spray. Intravenous meperidine and midazolam were administered during the procedure as needed. The success and safety of local anesthesia by lidocaine lollipop in addition to the need for intravenous sedation. Patients were equally randomized between the lollipop and the spray groups. The lollipop group had less gag reflex, accommodated scope introduction more, and tolerated the procedure better. Thirty-two percent of patients receiving the lollipop required sedation compared with 96% of patients in the spray group (P < .001). The majority in the lollipop group were satisfied with their mode of anesthesia compared with the spray group. Lidocaine lollipop is a promising form of local oropharyngeal anesthesia for EGD. Its use resulted in sparing the use of intravenous sedation. It is well tolerated and safe and may be particularly important in the elderly, patients with comorbidities, and office-based endoscopy.

Generalized Seizures Following Topical Lidocaine Administration During Circumcision

We report a case of neonatal seizures after lidocaine administration for circumcision. A 3-month-old male infant received an overdose as evidenced by toxic lidocaine levels and developed generalized seizures shortly after. Back extrapolation of the serum lidocaine concentration to time zero was used to determine the administered dose. The Naranjo scale was used to determine causation; probable causation was defined. Particular care must be taken to administer an appropriate dose of local anesthetics in infants to avoid life-threatening seizures.

Lidocaine Toxicity in Volunteer Subjects Undergoing Awake Fiberoptic Intubation

To the Editor: The paper by Martin et al. (1) raises serious concerns. Anesthesiologists acting as subjects on a training course in awake intubation were used to validate a training manikin. Martin et al. failed to set an upper dose limit for topical lidocaine administration and observed side effects indicating lidocaine toxicity. Death as a result of lidocaine toxicity has occurred in a healthy 19-yr-old college student volunteer after bronchoscopy for research purposes (2). That research protocol also failed to specify an upper dose limit for lidocaine. The safety of volunteers and subjects should be paramount. It is essential to specify an upper dose limit when using toxic drugs for research or when providing this type of training on volunteers. Nicholas M. Woodall, MBChB, FRCA Robert J. Harwood, MBBS, FRCA Graham L. Barker, MBBS, FRCA Department of Anaesthesia The Norfolk and Norwich University Hospital Norwich, U.K. [email protected]

Efficacy of lidocaine 2% gel in pterygium surgery

Anaesthesia during pterygium surgery is usually achieved with local injection of anaesthetic medications. The aim of this study was to determine whether lidocaine 2% gel is an effective topical anaesthetic agent for pterygium surgery. We conducted a prospective, randomized clinical trial. Fifty-four consecutive patients who had primary pterygium underwent surgical excision of the lesion and conjunctival autograft. Patients were randomized into two groups. Group 1 received 1 ml of lidocaine 2% solution subconjunctivally and group 2 received lidocaine 2% gel topically. The primary outcome of interest was the pain experienced during anaesthetic administration and surgery. Following the dissection and excision of the pterygium, conjunctival autograft was transplanted in each of the patients. Immediately after the operation, pain and discomfort scores were determined using a 10-point linear visual analogue scale. The mean pain score during anaesthetic administration was 4.26 +/- 1.18 in the injection group and 0.92 +/- 0.56 in the gel group. The mean pain score during surgery was 3.96 +/- 0.95 in the injection group and 4.0 +/- 1.01 in the gel group. There was a statistically significant difference in mean pain scores experienced during anaesthetic administration (p = 0.01). There was no significant difference in mean pain scores experienced during surgery (p = 0.55). No adverse events were noted. In light of these results, we conclude that topical administration of lidocaine 2% gel can be used as an alternative method of anaesthesia in pterygium surgery, especially for patients with needle phobia.

Enhancement of dorsal random-pattern skin flap survival in rats with topical lidocaine and prilocaine (EMLA): Enhancement of flap survival by EMLA

Various topical pharmacologic agents have been investigated for their efficacy in preventing or reversing skin flap ischemia. Most of these studies have focused on agents that act on the vascular smooth muscles to cause vasodilatation and improve circulation in the flap. Most of local anesthetics relax vascular smooth muscle and produce peripheral vasodilatation. Topical lidocaine administration was shown that it was an effective and prompt resolution of mechanically induced vasospasm. The topical analgesia cream, EMLA is a mixture of the substances lidocaine and prilocaine. EMLA causes a biphasic vascular response comprising initial blanching and vasoconstriction (maximal after 1.5 h of application) and late erythema and vasodilatation at application times longer than 3 h. To investigate the effect of EMLA on random flap survival, 40 rats were divided in 2 groups of 20 animals. Caudally based random pattern skin flaps were elevated on dorsa of the rats in 10 x 3 cm dimensions. In group 1 which was the treatment group, topical EMLA was applied and covered with Opsite for 1 week whereas in group 2 which was the control group, carrier for EMLA was applied to the flaps. At the end of treatment period, the areas of flap necrosis were measured and percentages of flap survivals were calculated. The mean percentages of flap survivals in group 1 and 2 were 81.2 +/- 1.2 percent and 58.7 +/- 2.3 percent, respectively. Topically administered EMLA might lead to a significant improvement in flap survival. In addition, it is safe, cost-effective, easily applied, and clinically available.

Toxicidad por administración tópica de lidocaína

It is frequently described in international literature the possibility of toxicity by local anesthesics. The lidocaine is one of them. The problems with its local use are more frequent and known but topic toxicity is also possible. We want to describe a case of toxicity by topical administration of lidocaine (Xylocain) which caused neurological disease with convulsions, and cardiological disease with ventricular fibrillation, in a patient who came for a thyroplasty. Patient's evolution was satisfactory.

Effects of Topical Ropivacaine on Eicosanoids and Neurotransmitters in the Rectum of Patients with Distal Ulcerative Colitis

Background: Topical administration of lidocaine has been suggested to have beneficial clinical effects in patients with active ulcerative colitis, but the mechanism of action, if any, remains obscure. As local anaesthetics may exert anti-inflammatory actions through their inhibition of nervous reflexes, we have studied the local effects of a single rectal dose of ropivacaine gel on rectal concentrations of eicosanoids and neurotransmittors in patients with relapsing ulcerative colitis. Methods: In a randomized, doubleblind, placebo-controlled study, concentrations of leukotriene B 4 , thromboxane B 2 and prostaglandin E 2 in rectal dialysates and concentrations of substance P, neurokinin A, somatostatin, vasoactive intestinal polypeptide and calcitonin gene-related peptide in rectal biopsies from 19 patients with active, distally located, ulcerative colitis were measured before and after rectal administration of a 200-mg dose of ropivacaine- or placebo-gel by use of radioimmunoassays. For comparison with normal conditions, concentrations of neuropeptides were measured in another 19 patients with relapsing ulcerative colitis and 14 controls with non-inflamed colon. Results: No significant changes in concentrations of eicosanoids or neuropeptides were observed after ropivacaine or placebo administration. Baseline concentrations of all neuropeptides, except somatostatin, were significantly lower in active ulcerative colitis than in controls with non-inflamed colon. Conclusions: These findings reveal no evidence of antiinflammatory actions by ropivacaine in active ulcerative colitis and thus provide no rationale for topical treatment with local anaesthetics.

Lidocaine-Induced Alterations in Agonist-Induced Ion Transport of Cultured Swine Tracheal Submucosal Gland Cells

It has been documented that topical administration of lidocaine can cause airway complications, although it is the most used local anesthetic for laryngotracheal anesthesia. Thus, in this study we investigated the local actions of lidocaine on basal and autonomic secretagogue-induced ion transport in cultured swine tracheal submucosal gland cells. Ion transport plays an important role in maintaining effective mucociliary clearance and pulmonary defense mechanisms. It was measured as short-circuit current (Isc) utilizing Ussing chamber methodology. Exposure of cultured gland cells to lidocaine evoked a transient response with an initial increase in Isc followed by a decrease. The increase in Isc induced by lidocaine (3 mM) was 8.0 ± 1.5 μA/cm2. The maximal increases in Isc induced by isoproterenol and acetylcholine were 9.4 ± 0.6 and 38.3 ± 2.3 μA/cm2, respectively. However, lidocaine significantly decreased the isoproterenol-induced increases in Isc. Acetylcholine-induced responses were not changed by lidocaine. Atropine did not significantly affect lidocaine-evoked events in ion transport. These results suggest that lidocaine directly alters epithelial transport of ions and also inhibits the adrenergic stimulation of epithelial ion transport.

Neurologic and Neurosurgical Emergencies.

Bingham and Women’s HospitalInstructorAssociate ProfessorDepartment of AnesthesiologyHarvard Medical SchoolBrigham and Women’s HospitalBoston, Massachusettsgcrosby@zeus.bwh.harvard.eduNeurologic and Neurosurgical Emergencies.Edited by Julio Cruz. Philadelphia, WB Saunders, 1998. Pages: 569. Cost: $145.00. This multiauthored, first-edition text is published under the auspices of the International Society for Neuroemergencies. According to the editor, a neurosurgeon, the goal was to integrate into a single volume the current basic and clinical sciences that guide the treatment of patients with neurologic or neurosurgical emergencies. The book is generally successful in this regard. The publication’s single greatest strength is that it is a multidisciplinary treatment of the topic and, as such, it reflects the different but complementary perspectives of various specialists. The book’s 20 chapters are written by 54 authors from specialties such as neurology, neurosurgery, radiology, anesthesiology, internal medicine, critical care, emergency medicine, pediatrics, rehabilitation medicine, and nursing. The chapters are generally well illustrated with useful tables, charts, and radiographs, and successfully place clinical management in the context of the available basic science. All of the chapters have a practical orientation, and whereas most are directed toward neurologists or neurosurgeons, anyone with an interest in neurologic emergencies will find an abundance of useful information.The first few chapters regarding the evaluation of the patient with neurologic injuries and the cardiac and respiratory complications that are associated with acute neurologic diseases are thorough and well referenced. These are followed by 15 chapters that are devoted to specific acute neurologic disorders, nursing care, predictors of long term prognosis, and rehabilitation. The chapters about the pediatric patient, neuroemergencies during pregnancy, subarachnoid and intracranial hemorrhage, intracranial and pituitary tumors, neuromuscular diseases, brain trauma, and acute spinal cord disorders are well written and will be of particular interest to anesthesiologists. As with any multiauthored text, there is some inevitable variation in writing style between chapters; however, the editor does a good job of minimizing redundancy and maintaining consistency. The majority of the references are current, and many references of historical importance are included. Chapter 14, which does not contain a single reference published within the last 10 years, is an exception to this generalization.A problem encountered when attempting to systematize the clinical management of patients who are severely ill is that the science, basic or clinical, that supports certain practices is often incomplete, conflicting, or is rapidly changing. This is certainly the case here. Statements about clinical management based on extrapolation of nonhuman data and clinical experience are common. To the book’s credit, however, these statements are frequently accompanied by the admonition that such extrapolations are suspect and that proper studies are lacking. This is exemplified in Chapter 9, in which the authors discuss and advocate use of “triple H therapy” for the management of cerebral vasospasm based on clinical experience, despite the lack of controlled, randomized studies to prove the treatment’s effectiveness. One area of much-current controversy and research that receives relatively superficial and anecdotal discussion is the use of moderate hypothermia in the setting of acute brain trauma. This is unfortunate, but not the rule; other timely topics (e.g. , thrombolytics for acute ischemic stroke, hyperventilation in the management of head trauma) receive more balanced and complete treatment.Clearly, this book is not is a replacement for a text about neurosurgical anesthesia or the anesthetic treatment of patients with neurologic disease. In fact, the discussion of anesthetic management tends to be superficial, of the “cook book” variety, or is frankly wrong. There are, for example, statements that etomidate should be given slowly for a rapid-sequence induction, that a nonrebreather mask delivers 100% oxygen, and that the hallmark of a good neuroanesthetic is “…deep anesthesia with neuromuscular blockade during intracranial micro-dissection…” Similarly, statements that a patient undergoing aneurysm clipping requires volume loading with albumin, placement of a central line, topical administration of lidocaine to the airway, and the use of a low-dose opioid technique reflect, at best, local biases that are not shared by the reviewers. Overall, Neurologic and Neurosurgical Emergencies is a scientifically grounded, thorough, and practical compendium of the issues surrounding the medical and surgical management of acute neurologic and neurosurgical conditions. The book is neither intended nor suited to be a stand-alone text for the anesthesiologist. It is, therefore, best viewed as a reference or resource for the anesthesiology trainee or the practicing anesthesiologist seeking a comprehensive review of the rationale for the clinical management of a broad range of neurologic and neurosurgical emergencies. In this regard, the book succeeds in achieving its stated purpose and will be a welcome addition to the departmental library.