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• W3155173847 abstract "Adequate topical anesthesia reduces discomfort and improves procedural tolerance during transesophageal echocardiography (TEE).1Hahn R.T. Abraham T. Adams M.S. Bruce C.J. Glas K.E. Lang R.M. et al.Guidelines for performing a comprehensive transesophageal echocardiographic examination: recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists.J Am Soc Echocardiogr. 2013; 26: 921-964Abstract Full Text Full Text PDF PubMed Scopus (569) Google Scholar Traditionally, in our practice, the physician has administered benzocaine before sedation. However, benzocaine use has been associated with methemoglobinemia.2Novaro G.M. Aronow H.D. Militello M.A. Garcia M.J. Sabik E.M. Benzocaine-induced methemoglobinemia: experience from a high-volume transesophageal echocardiography laboratory.J Am Soc Echocardiogr. 2003; 16: 170-175Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar, 3Kane G.C. Hoehn S.M. Behrenbeck T.R. Mulvagh S.L. Benzocaine-induced methemoglobinemia based on the Mayo Clinic experience from 28 478 transesophageal echocardiograms: incidence, outcomes, and predisposing factors.Arch Intern Med. 2007; 167: 1977-1982Crossref PubMed Scopus (78) Google Scholar, 4Barash M. Reich K.A. Rademaker D. Lidocaine-induced methemoglobinemia: a clinical reminder.J Am Osteopath Assoc. 2015; 115: 94-98PubMed Google Scholar The study objective was to assess nurse-administered topical lidocaine feasibility without benzocaine and its impact on methemoglobinemia rates. The study protocol was approved by the institutional review board. The study included 56,656 patients having TEE under moderate sedation between 2002 and 2019, with comparisons made before and after removing benzocaine in January 2009. We report the results of a nested continuous quality improvement (CQI) initiative performed in early 2009 with a comparison of physician-administered versus nurse-administered lidocaine ointment. During phase 1, before TEE, all patients received 1 inch of lidocaine 5% ointment applied in a protocolized manner by the physician. Data on patient satisfaction, level of anesthesia accomplished, and study timing were recorded. This was followed by phase 2, where all patients received the identical treatment of lidocaine, but it was administered by the TEE nurse prior to physician arrival. During both phases, if it was felt there was inadequate topical anesthesia, additional lidocaine could be given at the physician's discretion and was separately recorded. Between 2002 and 2008 all topical oropharyngeal sedation for TEEs (n = 18,955) was administered by the physician to combine topical benzocaine spray with or without lidocaine solution swish and swallow. There was a total of 17 cases of methemoglobinemia for an incidence rate of 0.09% (annual incidence, 0.07%-0.13%). All 17 received benzocaine and lidocaine swish and swallow. In January 2009, benzocaine spray was removed from our practice and replaced with lidocaine ointment. Comparing the phases of the CQI, administration by the RN facilitated time for onset of action and resulted in a superior suppression of the patient gag reflex (52% vs 36% gag reflex score of 5 [no gag]; P = .002; Figure 1), a shorter TEE procedure time (P = .007), and a lower rate of the need for supplemental topical lidocaine anesthesia (P = .002). Following completion of the CQI study, the clinical practice committee introduced an institution-approved medication administration protocol replicating phase 2 of the CQI. Between 2009 and 2019, a total of 37,701 TEEs were performed with lidocaine for topical oropharyngeal anesthesia. No patients developed methemoglobinemia as a complication of TEE following benzocaine discontinuation (P < .0001 compared to 2002-2008; Figure 2A). Throughout the study, patient weight increased by 7% from 84 ± 25 kg to 90 ± 25 kg (P < .0001) and average age by 3% from 63 ± 16 to 65 ± 15 years (P < .0001). In the postbenzocaine study phase (2009-2019), the average doses of midazolam administered were 8% lower at 3.4 ± 3 mg versus 3.7 ± 2 mg (2002-2008, P < .0001), and fentanyl doses were 5% higher at 62 ± 43 μg versus 59 ± 29 μg (P < .0001). Despite these modest changes in sedation dosing, fewer reversal agents were used (Figure 2B). While the use of naloxone administration was similar at 0.18% (2002-2008) and 0.17% (2009-2019; P = .80), the rates of flumazenil administration fell from 2.9% to 0.51% (P < .0001). The collective rate of use of either reversal agent fell from 3% to 0.58% (P < .0001). While studies to date suggest benzocaine is responsible for methemoglobinemia, frequently patients in these studies also received lidocaine in addition to benzocaine. Hence the contribution of lidocaine to TEE-related methemoglobinemia could not be excluded.2Novaro G.M. Aronow H.D. Militello M.A. Garcia M.J. Sabik E.M. Benzocaine-induced methemoglobinemia: experience from a high-volume transesophageal echocardiography laboratory.J Am Soc Echocardiogr. 2003; 16: 170-175Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar, 3Kane G.C. Hoehn S.M. Behrenbeck T.R. Mulvagh S.L. Benzocaine-induced methemoglobinemia based on the Mayo Clinic experience from 28 478 transesophageal echocardiograms: incidence, outcomes, and predisposing factors.Arch Intern Med. 2007; 167: 1977-1982Crossref PubMed Scopus (78) Google Scholar, 4Barash M. Reich K.A. Rademaker D. Lidocaine-induced methemoglobinemia: a clinical reminder.J Am Osteopath Assoc. 2015; 115: 94-98PubMed Google Scholar, 5Schelling V. Mattle D. Stahli C. Kraus M. Meier B. Widmer F. Sedation during transoesophageal echocardiography.Cardiovasc Med. 2015; 18: 215-219Crossref Google Scholar, 6Vallurupalli S. Manchanda S. Risk of acquired methemoglobinemia with different topical anesthetics during endoscopic procedures.Local Region Anesth. 2011; 4: 25-28Crossref PubMed Scopus (11) Google Scholar, 7Filipiak-Strzecka D. Kasprzak J.D. Wiszniewska M. Walusiak-Skorupa J. Lipiec P. The influence of lidocaine topical anesthesia during transesophageal echocardiography on blood methemoglobin level and risk of methemoglobinemia.Int J Cardiovasc Imaging. 2015; 31: 727-731Crossref PubMed Scopus (3) Google Scholar Here, assessing methemoglobinemia rates in over 50,000 TEE patients, we demonstrate that dosing of lidocaine to provide adequate anesthesia for TEE is not associated with a risk of methemoglobinemia, unlike benzocaine. Based on this evidence, removing benzocaine use from TEE practice is highly recommended. A protocolized nurse-administered strategy of topical oropharyngeal anesthesia was favorable to a physician-administered strategy. Here nurse administration allowed adequate time, typically 10 minutes, for lidocaine's full effects before the physician assessment of the patient. This convenient process led to better degrees of local anesthesia and ultimately translated into a degree of time efficiency saved. The quality pilot results led to our laboratory adopting this as our clinical standard. The protocol is straightforward. After completion of the preprocedure nursing assessment, if the patient does not have allergies to lidocaine, the nurse may proceed, per an institutionally approved protocol, to administer lidocaine 5% oral ointment, 1 inch on a tongue blade. The blade is placed with the ointment side down in the back of the patient's mouth, as far back as tolerated, with the patient instructed to swallow any dissolved ointment. After 2-3 minutes, the nurse checks the gag reflex. If a gag reflex remains, the nurse may repeat the lidocaine administration. No more than a total dose of 4.5 mg/kg of lidocaine can be given (7.5 inches for 70 kg patient), and the protocol recommends the first dose be administered within 10 minutes of the expected physician arrival time. Upon arrival, the physician performs the patient assessment including consent immediately prior to proceeding with the TEE. In summary, the discontinuation of benzocaine use resulted in removing methemoglobinemia and should be considered by those who are still using benzocaine for TEE. Furthermore, introducing a nurse-administered protocol of lidocaine ointment for topical anesthesia with TEE was feasible and may increase patient satisfaction." @default.
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• W3155173847 date "2021-07-01" @default.
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• W3155173847 title "Nursing Staff Administered Topical Lidocaine Anesthesia in Transesophageal Echocardiography: Impact on Quality, Delivery of Care, and the Rates of Methemoglobinemia" @default.
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