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A Suitable Substitute for 4% Cocaine before Blind Nasotracheal Intubation

3% Lidocaine–0.25% Phenylephrine Nasal Spray

Departments of Anesthesia, Nazareth Hospital, University of Pennsylvania, and Philadelphia Veterans Administration Medical Center, Philadelphia, Pennsylvania.

Abstract

To assess the efficacy of potential substitutes for cocaine as a topical anesthetic before nasal intubation, the authors performed a double-blind study comparing the hemodynamic effects of blind nasotracheal intubation in 75 patients receiving one of three nasal sprays: 4% cocaine (C), a mixture of 3% lidocaine in 0.25% phenylephrine (L-P), and 0.25% phenylephrine alone (P). Three minutes after 0.5 ml of one of the solutions was sprayed into each nostril, anesthesia and paralysis were induced with thiopental (5 mg/kg) followed by succinylcholine (1 mg/kg); immediately after induction, mean arterial pressure (MAP) and heart rate (HR) were recorded. After blind nasotracheal intubation was accomplished, MAP and HR were recorded for 5 min while anesthesia was maintained with 70% N₂O in O₂.

In patients receiving L-P, mean MAP during the 5 min after intubation decreased 2.3 ± 2.2 mm Hg (x ± SEM); this was significantly different from the increase of 6.2 ± 1.7 and 8.5 ± 2.0 mm Hg in MAP after intubation of patients receiving C and P, respectively (P < 0.005). Although mean HR decreased during the 5 min after intubation in all groups, this decrease was significantly greater (9.6 ± 1.4 beats/min) in patients receiving L-P than in those receiving C (3.1 ± 1.6 beats/min) or P (0.1 ± 1.7 beats/min) (P < 0.005). Changes in HR and MAP were similar in patients receiving C and P. There was no significant difference in the incidence or severity of epistaxis among the three groups. The authors conclude that for nasotracheal intubation, topical 3% lidocaine in 0.25% phenylephrine is as effective as 4% cocaine. Because of cocaine's toxicity and the potential for its abuse, the use of a lido-caine-phenylephrine mixture should be encouraged.

Key Words: ANESTHETICS LOCAL-cocaine lidocaine • INTUBATION—nasotracheal

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Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999