Pediatric Drugs

, Volume 21, Issue 1, pp 25–31 | Cite as

Topical Pharyngeal Lidocaine Reduces Respiratory Adverse Events During Upper Gastrointestinal Endoscopies Under Ketamine Sedation in Children

  • Jose Carlos Flores-GonzálezEmail author
  • Ana Estalella-Mendoza
  • Patricia Rodríguez-Campoy
  • Mónica Saldaña-Valderas
  • Alfonso M. Lechuga-Sancho
Short Communication



Upper gastrointestinal endoscopies (UGEs) performed under ketamine sedation may increase the risk of respiratory adverse events (RAEs) due to pharyngeal stimulation. Topical lidocaine prevents general anesthesia-induced laryngospasm.


Our objective was to determine whether topical lidocaine may reduce the incidence of RAEs induced by pharyngeal stimulation in UGEs performed on children sedated with ketamine.


We conducted a single-center prospective study. We included every patient admitted for an elective diagnostic UGE under ketamine sedation who received lidocaine prior to the technique. Patients requiring any other medication were excluded. Our main outcome measure was the number of desaturation episodes. We then compared these results with those obtained in an historic group who did not receive topical lidocaine, in which we registered a total of 54 desaturation episodes.


In total, 88 children (52.3% boys) were included. The median age was 7 years [interquartile range (IQR) 3–11]. The mean duration of the procedure was 6.5 ± 2.4 min, and the median initial ketamine dose was 1.76 mg/kg (IQR 1.56–2.03). The total number of desaturation episodes was 3 (3.4%), and two of these occurred prior to the introduction of the endoscope. This result represents a lower incidence than in previously reported series, and a significant decrease (p < 0.0001) with respect to the 54 RAEs registered in the historic group of 87 children.


Topical lidocaine premedication significantly reduced the incidence of RAEs in children during UGEs under ketamine sedation. Our findings should be confirmed by a double-blind randomized controlled trial.


Compliance with Ethical Standards

Conflict of Interest

JCFG, AEM, PRC, MSV, and AMLS have no conflicts of interest that are directly relevant to the content of this article.


No sources of funding were used to conduct this study or prepare this manuscript.

Ethical approval and informed consent

The study was approved by the appropriate institutional review board (Research Committee of Cádiz), and written informed consent was obtained from all subjects, a legal surrogate, or the parents or legal guardians for minor subjects.


  1. 1.
    Green SM, Krauss B. Clinical practice guideline for emergency department ketamine dissociative sedation in children. Ann Emerg Med. 2004;44:460–71.CrossRefGoogle Scholar
  2. 2.
    Akbulut UE, Saylan S, Sengu B, Akcali GE, Erturk E, Cakir M. A comparison of sedation with midazolam-ketamine versus propofol-fentanyl during endoscopy in children: a randomized trial. Eur J Gastroenterol Hepatol. 2017;29:112–8.CrossRefGoogle Scholar
  3. 3.
    Munro A, Machonochie I. Midazolam or ketamine for procedural sedation of children in the emergency department. Emerg Med J. 2007;24:579–80.CrossRefGoogle Scholar
  4. 4.
    Cheuk DK, Wong WH, Ma E, et al. Use of midazolam and ketamine as sedation for children undergoing minor operative procedures. Support Care Cancer. 2005;13:1001–9.CrossRefGoogle Scholar
  5. 5.
    Roback MG, Wathen JE, MacKenzie T, Bajaj L. A randomized, controlled trial of i.v. versus i.m. ketamine for sedation of pediatric patients receiving emergency department orthopedic procedures. Ann Emerg Med. 2006;48:605–12.CrossRefGoogle Scholar
  6. 6.
    Trimmel H, Helbok R, Staudinger T, et al. S(+)-ketamine: current trends in emergency and intensive care medicine. Wien Klin Wochenschr. 2018;130:356–66.CrossRefGoogle Scholar
  7. 7.
    Green SM, Roback MG, Krauss B, et al. Predictors of airway and respiratory adverse events with ketamine sedation in the emergency department: an individual-patient data meta-analysis of 8,282 children. Ann Emerg Med. 2009;54:158–68.CrossRefGoogle Scholar
  8. 8.
    Flores-Gonzalez JC, Lechuga Sancho AM, Saldana VM et al. Respiratory adverse events during upper digestive endoscopies in children under Ketamine sedation. Minerva Pediatr 2017 (Epub ahead of print).Google Scholar
  9. 9.
    Eskander AE, Baroudy NR, Refay AS. Ketamine sedation in gastrointestinal endoscopy in children. Open Access Maced J Med Sci. 2016;4:392–6.CrossRefGoogle Scholar
  10. 10.
    Green SM, Klooster M, Harris T, Lynch EL, Rothrock SG. Ketamine sedation for pediatric gastroenterology procedures. J Pediatr Gastroenterol Nutr. 2001;32:26–33.CrossRefGoogle Scholar
  11. 11.
    Mihara T, Uchimoto K, Morita S, Goto T. The efficacy of lidocaine to prevent laryngospasm in children: a systematic review and meta-analysis. Anaesthesia. 2014;69:1388–96.CrossRefGoogle Scholar
  12. 12.
    Sanikop C, Bhat S. Efficacy of intravenous lidocaine in prevention of post extubation laryngospasm in children undergoing cleft palate surgeries. Indian J Anaesth. 2010;54:132–6.CrossRefGoogle Scholar
  13. 13.
    Doyle DJ, Garmon EH. American Society of Anesthesiologists Classification (ASA Class). StatPearls. (2018).Google Scholar
  14. 14.
    Grunwell JR, Travers C, McCracken CE, et al. Procedural sedation outside of the operating room using ketamine in 22,645 children: a report from the pediatric sedation research consortium. Pediatr Crit Care Med. 2016;17:1109–16.CrossRefGoogle Scholar
  15. 15.
    Green SM, Roback MG, Kennedy RM, Krauss B. Clinical practice guideline for emergency department ketamine dissociative sedation: 2011 update. Ann Emerg Med. 2011;57:449–61.CrossRefGoogle Scholar
  16. 16.
    Krauss B, Green SM. Procedural sedation and analgesia in children. Lancet. 2006;367:766–80.CrossRefGoogle Scholar
  17. 17.
    Mason KP, Green SM, Piacevoli Q. Adverse event reporting tool to standardize the reporting and tracking of adverse events during procedural sedation: a consensus document from the World SIVA International Sedation Task Force. Br J Anaesth. 2012;108:13–20.CrossRefGoogle Scholar
  18. 18.
    Green SM, Kuppermann N, Rothrock SG, Hummel CB, Ho M. Predictors of adverse events with intramuscular ketamine sedation in children. Ann Emerg Med. 2000;35:35–42.CrossRefGoogle Scholar
  19. 19.
    Meyer S, Aliani S, Graf N, Reinhard H, Gottschling S. Sedation with midazolam and ketamine for invasive procedures in children with malignancies and hematological disorders: a prospective study with reference to the sympathomimetic properties of ketamine. Pediatr Hematol Oncol. 2003;20:291–301.CrossRefGoogle Scholar
  20. 20.
    Krauss B, Green SM. Sedation and analgesia for procedures in children. N Engl J Med. 2000;342:938–45.CrossRefGoogle Scholar
  21. 21.
    Deitch K, Miner J, Chudnofsky CR, Dominici P, Latta D. Does end tidal CO2 monitoring during emergency department procedural sedation and analgesia with propofol decrease the incidence of hypoxic events? A randomized, controlled trial. Ann Emerg Med. 2010;55:258–64.CrossRefGoogle Scholar
  22. 22.
    Green SM, Krauss B. Supplemental oxygen during propofol sedation: yes or no? Ann Emerg Med. 2008;52:9–10.CrossRefGoogle Scholar
  23. 23.
    Green SM, Pershad J. Should capnographic monitoring be standard practice during emergency department procedural sedation and analgesia? Pro and con. Ann Emerg Med. 2010;55:265–7.CrossRefGoogle Scholar
  24. 24.
    Gulhas N, Durmus M, Demirbilek S, Togal T, Ozturk E, Ersoy MO. The use of magnesium to prevent laryngospasm after tonsillectomy and adenoidectomy: a preliminary study. Paediatr Anaesth. 2003;13:43–7.CrossRefGoogle Scholar
  25. 25.
    Roberts MH, Gildersleve CD. Lignocaine topicalization of the pediatric airway. Paediatr Anaesth. 2016;26:337–44.CrossRefGoogle Scholar
  26. 26.
    Hamilton ND, Hegarty M, Calder A, Erb TO, von Ungern-Sternberg BS. Does topical lidocaine before tracheal intubation attenuate airway responses in children? An observational audit. Paediatr Anaesth. 2012;22:345–50.CrossRefGoogle Scholar
  27. 27.
    Qi X, Lai Z, Li S, Liu X, Wang Z, Tan W. The efficacy of lidocaine in laryngospasm prevention in pediatric surgery: a network meta-analysis. Sci Rep. 2016;6:32308.CrossRefGoogle Scholar
  28. 28.
    Basturk A, Artan R, Yilmaz A. Efficacy and safety of midazolam and ketamine in paediatric upper endoscopy. Arab. J Gastroenterol. 2017;18:80–2.Google Scholar

Copyright information

© Springer Nature Switzerland AG 2018

Authors and Affiliations

  1. 1.Pediatric Intensive Care UnitPuerta del Mar University HospitalCádizSpain
  2. 2.Clinical Farmacology UnitPuerta del Mar University HospitalCadizSpain
  3. 3.Mother and Child Health, and Radiology DepartmentCádiz UniversityCadizSpain
  4. 4.Institute of Research and Innovation in Biomedical Sciences (INIBiCA)CadizSpain

Personalised recommendations