Anesthesiology

A nasal spray containing lidocaine and phenylephrine appears to be no better than placebo in relieving procedure-relate distress in infants and young children undergoing nasogastric-tube insertion, Australian researchers are find. “Having a nasogastric tube placed is really uncomfortable. There are studies in adults which suggest that they make it hurt less by using a numbing medication; either with a spray, or gel, or as an inhaled mist,” Dr. Simon Craig of Monash Medical Centre, in Melbourne, told Reuters Health by email.

Placebo in relieving procedure

“It is almost impossible in a young child to work out whether they are upset during a procedure because it hurts; or because it is scary, or because it’s yucky having something place in your nose and down your throat;” he explain. “In young children, usual practice in most places is just to hold them still while the procedure is doing; without much pain relief. Unfortunately; the procedure is quite distressing; and we were hoping to demonstrate that the use of medication in children might help,” Dr. Craig added.

He and his colleagues conducted a double-blind, randomized; placebo-control superiority trial in 100 children ages 6 months to 5 years who are assign to receive either a commercially available nasal spray with 5% lidocaine hydrochloride and 0.5% phenylephrine hydrochloride or placebo (0.9% sodium chloride) The study; online April 15 in The Lancet Child and Adolescent Health; is the first adequately powered trial to evaluate the effectiveness of topical local anesthetic and vasoconstrictor use before nasogastric tube insertion in children in that age range; the researchers say.

Available nasal spray

It was based on a convenience sample of patients who were slated to have a nasogastric tube inserted as part of treatment in the emergency department of a tertiary referral center from 2014 to 2017. The most common reason for tube insertion was dehydration arising from gastroenteritis. One spray of active medication delivered 5 mg lidocaine and 0.5 mg phenylephrine. Children weighing 6-12 kg received one spray to each nostril; and children over 12 kg received two sprays to each nostril.

The primary outcome was procedure-relate distress as measure with the Face, Legs, Activity, Cry and Consolability (FLACC) scale. There was no between the treatment and placebo groups in the median FLACC score between active treatment (9) and placebo (9) during insertion. Dr. Craig advised clinicians to “remember how uncomfortable nasogastric tubes are.

Local anesthetic spray

We should only use them when necessary, and do our best to manage distress relating to their insertion with whatever means we have,” including local anesthetic spray, sedation, or both. In a linked editorial, Dr. Rebeccah Slater of the department of pediatrics at the University of Oxford John Radcliffe Hospital, in the U.K., highlights the fact that “in more than 30% of the children in each group nasogastric tube insertion evoked the maximum FLACC score, limiting the discriminative ability of the outcome measure for this procedure.”