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 Table of Contents  
Year : 2015  |  Volume : 2  |  Issue : 3  |  Page : 85-88

Comparison of intubation conditions with halothane suxamethonium and halothane topical lidocaine 2% in children undergoing

Department of Anesthesia and Intensive Care, Faculty of Medicine, Zagazig University, Zagazig, Egypt

Date of Submission20-May-2015
Date of Acceptance21-Sep-2015
Date of Web Publication30-Dec-2015

Correspondence Address:
Osama YA Khalifa
MD, Department of Anesthesia, Zagazig Medical Faculty, Assharkia, Zagazig 44519
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2356-9115.172798

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Suxamethonium has several side effects, particularly in children, including apnea, bradycardia, hyperkalemia, and the fatal side effect malignant hyperthermia. Looking for a safe, available and cheap alternative to suxamethonium is the aim of this study.
Patients and Methods
Sixty children admitted for adenoidotonsillectomy aged between 3 and 8 years were classified into two groups. Group HS was formed of 30 patients anesthetized using inhalational halothane 5% and suxamethonium 1.5 mg/kg. Group HL was formed of 30 patients who were anesthetized with halothane 5% and topical oral lidocaine solution 2% at a dose of 4 mg/kg. The intubation conditions score was applied in both groups.
There was a nonsignificant difference between the two groups as regards the hemodynamic parameters both before and after intubation. There was also a nonsignificant difference in intubation conditions score between the two groups.
Lidocaine 2% oral solution at a dose of 4 mg/kg before intubation produces similar hemodynamics and intubation conditions to suxamethonium in adenoidotonsillectomy in children aged 3-8 years.

Keywords: Children, intubation, lidocaine 2%, suxamethonium

How to cite this article:
Khalifa OY, Saadalla AE. Comparison of intubation conditions with halothane suxamethonium and halothane topical lidocaine 2% in children undergoing. Res Opin Anesth Intensive Care 2015;2:85-8

How to cite this URL:
Khalifa OY, Saadalla AE. Comparison of intubation conditions with halothane suxamethonium and halothane topical lidocaine 2% in children undergoing. Res Opin Anesth Intensive Care [serial online] 2015 [cited 2020 Jun 2];2:85-8. Available from: http://www.roaic.eg.net/text.asp?2015/2/3/85/172798

  Introduction Top

Suxamethonium is a depolarizing muscle relaxant that has the advantage of producing rapid onset of profound muscle relaxation that allows easy endotracheal intubation. This drug has a poor reputation because of multiple side effects that may accompany its use, particularly in children - for example, bradycardia, hyperkalemia, apnea, and malignant hyperthermia. The current study borrows the idea of using topical oral lidocaine 2% solution in awake fiberoptic intubation and apply it to produce anesthesia of the airway mucosa to facilitate intubation without the use of suxamethonium.

Many drugs have been used to facilitate end tracheal intubation without the use of muscle relaxants. Tracheal intubation conditions were good or excellent after remifentanyl at 4 μg/kg and propofol at 2 mg/kg without muscle relaxation, whereas in the case of alfentanyl excellent conditions for intubation were possible only when the dose was 40 μg/kg [1].

Intubation conditions with halothane 5% at a nitrous/oxygen ratio of 60/40% were more ideal than those with sevoflorane 8% at a nitrous/oxygen ratio of 60/40%. However, tracheal intubation was successful at the first attempt in all children undergoing adenoidotonsillectomy and all remained with stable hemodynamics [2].

The most important complications from tonsillectomy and adenoidectomy are bleeding, stridor, and laryngospasm. Both topical lidocaine 2% solution at 4 mg/kg before end tracheal intubation and intravenous lidocaine 2% at 1 mg/kg before extubation revealed less stridor and laryngospasm compared with the control group in children undergoing adenoidotonsillectomy; there was no difference between topical and intravenous lidocaine except that intravenous lidocaine produced higher sedation scores in the early postoperative period [3].

Eqeli and colleagues suggested that topical lidocaine 2% with adrenaline-soaked swabs packed in tonsillar fossae is a safe and easy local anesthetic. However, in their study, lidocaine with adrenaline-soaked swabs offered no advantage over placebo in the control of postoperative pain and other morbidity-related factors like nausea, fever, vomiting, odor, bleeding, otalgia, and tresmus [4].

  Patients and methods Top

After obtaining informed parental consent 60 patients aged 3-8 years undergoing adenoidotonsillectomy were randomly allocated into two groups: group HS was given halothane 5% and suxamethonium at 1.5 mg/kg for endotracheal intubation; group HL was given halothane 5% and topical oral 2% lidocaine solution at a dose of 4 mg/kg. All patients were monitored for heart rate, oxygen saturation, and noninvasive arterial blood pressure throughout the procedure; a reading was taken before laryngoscopy and another reading 1 min after intubation. No anticholinergic was given. Inhalation of halothane 5% was continued until patients were adequately anesthetized as denoted by centralization and small size of the pupil. At this level of anesthesia intravenous suxamethonium was given at a dose of 1.5 mg/kg in group HS and oral lidocaine 2% solution at a dose of 4 mg/kg was applied into the oral cavity, with spontaneous respiration enabling the solution to be aspirated and cover the airway. Endotracheal intubation was started after 90 s in both groups to allow optimum action of suxamethonium and lidocaine.

Laryngoscopy was performed with a Macintosh laryngoscope blade, and the trachea was intubated with an uncuffed tube of appropriate size.

An expert single anesthetist performed the intubation and assessed the intubation conditions in all cases on the basis of the intubation conditions score.

The demographic data, hemodynamics, oxygen saturation, and intubation conditions score of both groups were compared.

We used the Steyn modification of the Helbo-Hansen intubation conditions scoring system [Table 1]. This system comprises five categories; each of them is assessed and given a score from 1 to 4. The intubation conditions are considered excellent if all category scores are 1; if any category score is 2 the conditions are considered good; both good and excellent conditions indicate acceptable intubation. If any category score is more than 2, intubation conditions are considered not accepted.
Table 1: Steyn modification of the Helbo– Hansen intubation condition scoring system [5]

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Exclusion criteria

We excluded from the study patients with upper respiratory tract infections in the previous 3 weeks, patients with known allergy to any of the study drugs, and patients with anticipated difficult intubation.

Statistical analysis

Data were checked, entered, and analyzed using SPSS (version 20; SPSS Inc., Chicago, Illinois, USA). Data were expressed as number and percentage. The χ2 and Fisher exact test or the t-test was used when appropriate. P values less than 0.05 were considered statistically significant.

  Results Top

Difference in age between the two groups was insignificant, as shown in [Table 2].
Table 2: Mean age of both groups

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Recorded readings of oxygen saturation, heart rate, systolic blood pressure, and diastolic blood pressure were nonsignificant between the two groups before and after intubation, as shown in [Table 3],[Table 4],[Table 5] and [Table 6].
Table 3: Heart rate readings in both groups before and after intubation

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Table 4: Oxygen saturation in both groups before and after intubation

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Table 5: Systolic blood pressure in both groups before and after intubation

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Table 6: Diastolic blood pressure before and after intubation

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The intubation conditions were accepted in 100% of patients in both groups, and there was a nonsignificant difference between the two groups as regards the intubation conditions score, as shown in [Table 7].
Table 7: Intubation condition score in both groups

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  Discussion Top

There was a nonsignificant difference in age between the two groups. There was a nonsignificant difference in oxygen saturation, heart rate, and blood pressure between the two groups either before or after intubation.

In the current study we found that both suxamethonium and topical lidocaine 2% at a dose of 4 mg/kg produced similar intubation conditions after inhalational induction with halothane 5% in children undergoing adenoidotosillectomy, and hemodynamic parameters were similar.

Many studies used topical lidocaine to facilitate endotracheal intubation without muscle relaxation. In agreement with this study, Veyckemans et al. [6] considered inhalational induction with halothane in oxygen and a spray of 2 mg/kg lidocaine on vocal cords as a safe alternative to awake endotracheal intubation in neonates; intubation thus performed was easy, nontraumatic, well suited for training, and more humane. However, the current study used lidocaine at a dose of 4 mg/kg as the children were older than those in the study by Veyckemans and colleagues and the current dose was below the toxic dose of lidocaine.

Jin et al. [7] found that laryngotracheal administration of 4% lidocaine spray could increase the percentage of acceptable conditions for tracheal intubation during propofol and remifentanil anesthesia without neuromuscular blockade. In their study, intubation conditions were accepted in 88% of patients who received topical lidocaine, but in this study it was 100%. This may be because we gave lidocaine 4 mg/kg, whereas Jin and colleagues used a total dose of 140 mg in adult patients; in addition, we waited for 90 s after application of topical lidocaine, whereas Jin and colleagues waited for only 60 s.

Hamaya and Dohi [8] suggested that the inhibition of airway tactile stimulation with topical lidocaine could be mainly due to direct blockade of the mechanoreceptors of airways and partly due to its systemic effect. They found the peak serum lidocaine concentration to be at 5-10 min after laryngeal application of 200 mg lidocaine. In this study we used topical lidocaine and waited for 90 s to perform intubation; thus, the probability of systemic effects was minimal.

Morgan et al. [9] found that intubation conditions were assessed as good or excellent in 86.6% of patients who took succinylcholine for intubation after propofol induction. In this study, intubation conditions were excellent to good in 100% of patients who took succinylcholine after inhalational induction with halothane 5%. This may be due to the deep anesthesia produced by halothane as we waited until the pupils became central and constricted. Morgan and colleagues also found the heart rate to be significantly increased after succinylcholine and propofol, but we did not; this may be because of the effect of halothane.

  Conclusion Top

Lidocaine 2% oral solution at a dose of 4 mg/kg before intubation is a safe alternative to succinylcholine and produces similar accepted intubation conditions in adenoidotonsillectomy in children aged 3-8 years.

  Acknowledgements Top

Conflicts of interest

None declared.

  References Top

Erthan E, Ugur G, Alper I, Gunusen I, Ozyar B. Tracheal intubation without muscle relaxants: remifentanyl or alfentanyl in combination with propofol. Eur J Anaesthesiol 2003; 20:37-43.  Back to cited text no. 1
O′Brien k, Kumar R, Morton NS. Sevoflurane compared with halothane for tracheal intubation in children. Br J anaesth 1998; 80:452-455.  Back to cited text no. 2
Koc C, Kocaman F, Aygenc E, Ozdem C, Cekic A. The use of preoperative lidocaine to prevent stridor and laryngospasm after tonsillectomy and adenoidectomy. Otolaryngol Head Neck Surg 1998; 118:880-882.  Back to cited text no. 3
Eqeli E, Harputluoqlu U, Oghan F, Demiraran Y, Guclu E, Ozturk O. Does topical lidocaine with adrenaline have an effect on morbidity in pediatric tonsillectomy ? Int J pediatr Otorhinolaryngol 2005; 69:811-815.  Back to cited text no. 4
Steyn MP, Quinn AM, Gillespie JA, Miller DC, Best CJ, Morton NS. Tracheal intubation without neuromuscular block in children. Br J Anaesth 1994; 72:403-406.  Back to cited text no. 5
Veyckemans F, Matta A, Gribomont BF, Kestens-Servaye Y. A safe alternative to awake intubation in neonates. Acta Anaethesiol Belg 1985; 36:143-150.  Back to cited text no. 6
Jin SK, Dae HK, Han BJ, Chang KO,Jong YK. Effect of tracheal lidocaine on intubating conditions during propofolramifentanil target-controlled infusion without neuromuscular blockade in day case anesthesia. Korean J Anesthesiol 2013; 65:425-430.  Back to cited text no. 7
Hamaya Y, Dohi S. Differences in cardiovascular response to airway stimulation at different sites and blockade of the responses by lidocaine. Anesthesiology 2000; 93:95-103.  Back to cited text no. 8
Morgan JM, Barker I, Peacook JE, Eissa A. A comparison of intubating conditions in children following induction of anaesthesia with propofol and suxamethonium or propofol and remifentanil. Anaesthesia 2007; 62:135-139.  Back to cited text no. 9


  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]


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