IV Lidocaine to Prevent the Increases in ICP with Endotracheal Suctioning

IV Lidocaine to Blunt the Increases in ICP with Endotracheal Suctioning

Take Home Point:

Evidence regarding the ability of intravenous (IV) lidocaine to suppress transient increases in increased cranial pressure (ICP) with endotracheal suctioning is mixed and does not evaluate the relevance of treating a potential, transient rise in ICP on neurologic outcome.

Summary:

The administration of IV lidocaine has been reported to suppress the potential rise in intracranial pressure (ICP) caused by endotracheal suctioning. This would be particularly important for patients with acute head injuries, where elevations in ICP are purported to compromise neurological outcomes.

IV lidocaine is hypothesized to work by two mechanisms:

By blunting the cough reflex, and thus the reflexive rise in ICP

By suppressing the "pressor response" - the rise in heart rate and blood pressure caused by a catecholamine release during endotracheal stimulation

Evidence in support of the use of IV lidocaine for ICP reduction during endotracheal suctioning is based on a number of small, underpowered studies examining either intubated ICU patients or healthy volunteers conducted several decades ago. Intracranial pressure was measured in the majority of the studies via a subarachnoid pressure screw, and cohorts included an average number of 10. These early studies reported a significant decrease in the observed cough reflex and blunting of any increase in ICP with suctioning. Methods and results were incompletely reported.

Relatively more recent evidence, including a randomized study by White et al., reject the efficacy of IV lidocaine in reducing ICP and suggest that cerebral perfusion pressure (CPP) is not altered at all during endotracheal suctioning due to a concomitant rise in mean arterial pressure (MAP) with suctioning (CCP=MAP-ICP).

All studies used a standard dose of IV lidocaine at 1.5 mg/kg. No studies reported the effect on neurological outcome and therefore raise questions as to the relevance of the proposed treatment.

Author: Karolina DeAugustinis, MD
Editor(s): Anthony J. Busti, MD, PharmD, FNLA, FAHA
Date Last Reviewed: August 2015

Supporting Guidelines
To our knowledge there are no guidelines or position statements by any professional organization that recommend lidocaine be used prior to endotracheal suctioning of patients with concerns for increased intracranial pressure (ICP).

Landmark or Original Studies

Donegan et al. Intravenously administered lidocaine prevents intracranial hypertension during endotracheal suctioning. Anesthesiology 1980:52:516-18. PubMed

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Poulton et al. Cough suppression by lidocaine. Anesthesiology 1979:50(5), 470-472. PubMed

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White et al. A randomized study of drugs for preventing increases in intracranial pressure during endotracheal suctioning. Anesthesiology 1982:57:242-4. PubMed

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Level of Evidence	1b
Study Design	Prospective, Randomized, Controlled Trial
Sample Size	N = 15
Population	ICU patients with diffuse brain jury and intraventricular cannulae and endotracheal tubes
Inclusion Criteria	Patients were studied IF they developed rise in ICP during or after endotracheal suctioning
Exclusion Criteria	Not reported
Interventions	(Control) normal saline (2ml) vs (Interventions) fentanyl (1μg/kg), thiopental (3mg/kg), lidocaine (1.5mg/kg) or succinylcholine (1mg/kg) prior to endotracheal suctioning. ICP was measured before, during and after suctioning. Each patient received all treatments and these were repeated 2-8 times in different sequences.
Other Treatments	Steroids (unspecified), osmotic dehydrating agents (unspecified), diazepam and morphine for sedation.
Follow Up	3-5 minutes after endotracheal suctioning
Primary Endpoint	ICP and MAP measurements before (base), during (peak) and 3-5 minute after standard endotracheal suctioning protocol.
Secondary Endpoint	Cough score during endotracheal suctioning
Results	Fentanyl had no effect on ICP, nor did it blunt the expected rise in ICP with suctioning Thiopental and IV lidocaine both caused an initial decrease in ICP of 4-6 mmHg, but neither effected the subsequent rise in ICP with endotracheal suctioning Intratracheal lidocaine caused cough with instillation into the trachea so initially increased ICP. It then was more effective in blunting the rise in ICP with suctioning than IV. (peak rise in ICP +11 vs +19 for IV lidocaine, +22 for normal saline) p<0.05 Succinylcholine significantly prevented any rise in ICP with suctioning (peak ICP +3, p<0.01). CPP was not altered by ANY of the regimes as there was a concomitant rise in MAP (CCP=MAP-ICP)
Comments	Underpowered study Patients acted as their own controls Contradicts earlier studies in favor of IV lidocaine to prevent increases in ICP Patient population of diffuse head injury more applicable to question of whether lidocaine in RSI of patients with acute head injury will prevent ICP rise

Related Articles
Takeshima et al. Cardiovascular response to rapid anaesthesia induction and endotracheal intubation. Anaesth Analg 1964;43:201-8. Steinhaus et al. A study of intravenous lidocaine as a suppressant of cough reflex. Anesthesiology 1962:24, 285-290.

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MESH Terms or Keywords
Lidocaine Prevention ICP ET Suctioning, Preventing Increases in ICP with Lidocaine

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IV Lidocaine to Blunt the Increases in ICP with Endotracheal Suctioning

Supporting Guidelines

Landmark or Original Studies

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MESH Terms or Keywords