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High Dose Lidocaine use in Fiberoptic Bronchoscopy

Brooke Army Medical Center, San Antonio, TX

PURPOSE: Topical lidocaine during fiberoptic bronchoscopy (FOB) improves patient comfort. The maximum dose tolerable without toxicity isn’t clearly established. A maximum dose of < 8.2 mg/kg is advocated. Review of our institution’s lidocaine use revealed a mean of 12.1 mg/kg. We prospectively evaluated the safety of topical lidocaine during FOB.

METHODS: Our institutional FOB preparation includes 5-10 ml 4% nebulized lidocaine, 5-10 ml 2% viscous lidocaine (nasal mucosa), 10-20 ml 2% aqueous lidocaine (vocal cords), as needed 1% aqueous lidocaine (tracheobronchial tree), and conscious sedation with cardiac monitoring. Post-procedure data was collected from FOB patients, including total lidocaine, symptoms of toxicity, potential drug interactions, and procedure indication. Serum lidocaine and blood methemoglobin levels were obtained 45 minutes post-procedure. Statistical interpretation included t-tests and ANOVA. FOB operators were blinded. The study was approved by the Institutional Review Board.

RESULTS: Of 170 consecutive FOBs, data was available for 135 patients with mean age 64.7 years (range 20-89), 84 (62.2%) male, and 43 (31.9%) receiving beta-blockade. The most common indication (58.5%) was mass/adenopathy. None had significant hepatic disease. Symptoms of euphoria or dizziness were reported in 84 (62.2%) post-procedure. No abnormalities on cardiac monitoring were noted. Total mean lidocaine usage was 15.2 ± 4.4 mg/kg. Usage in females was significantly more than males (17.1 ± 4.5 versus 14.0 ± 3.8 mg/kg, p= < 0.0001). There was no difference in usage based on age, indication, beta-blockade, or presence of symptoms. Mean post-procedure lidocaine level (normal 1.2 –5.0 mcg/ml) was 1.6 ± 0.7 (range 0.8 –5.1) mcg/ml. Mean methemoglobin level (normal 0.4 –1.2 percent) was 0.7 ± 0.3 (range 0.1 –1.9) percent. There was no difference based on sex, age, indication, beta-blockade, or presence of symptoms.

CONCLUSION: Our use of lidocaine in FOB is higher than commonly recommended. This does not translate into significantly elevated patient serum lidocaine or methemoglobin levels.

CLINICAL IMPLICATIONS: Higher doses of lidocaine than are currently recommended may be safely used in FOB.

DISCLOSURE: W.C. Frey, None.