Pretreatment with intranasal lidocaine may reduce pain associated with intranasal midazolam for procedural sedation in children 6-12 years old

EBM Focus - Volume 12, Issue 8

Reference - Acad Emerg Med 2017 Feb;24(2):161 (level 2 [mid-level] evidence)

  • Intranasal midazolam may alleviate anxiety and provide sedation in children having procedures, but administration may be painful and irritating.
  • A recent trial randomized 77 children aged 6-12 years having intranasal midazolam for procedural sedation to pretreatment with lidocaine hydrochloride 4% vs. saline into both nostrils via mucosal atomizer.
  • Median nasal pain immediately after intranasal midazolam administration was 3 (out of 10) with lidocaine vs. 8 with saline (p = 0.006).

Intranasal midazolam may be used to alleviate anxiety and provide sedation in children having some medical procedures, but its administration may be painful and irritating (NICE 2010 Dec:CG112, Cochrane Database Syst Rev 2016 May 20;(5):CD009491). A case-series suggests that topical atomized lidocaine delivered into the nostrils before intranasal midazolam administration may reduce this pain in young children (Arch Dis Child 2011 Feb;96(2):160), but comparative studies are needed. To better assess the efficacy of pretreatment with lidocaine, a recent trial randomized 77 children aged 6-12 years having intranasal midazolam for procedural sedation in a pediatric emergency department to pretreatment (5 minutes before sedation) with lidocaine hydrochloride 4% vs. 0.9% saline 0.25 mL into each nostril via mucosal atomizer. The most common procedures to be performed were laceration repair or other wound management (in 77.5% of children) and fracture reduction (in 14.5%). Children were excluded for sedation for non-procedural reasons, moderate-to-severe asthma or chronic lung disease, copious nasal discharge, conditions for which moderate sedation may have complications, and life-threatening conditions. There were no significant differences between groups in demographic assessments or indications for procedural sedation. However, baseline anxiety levels, pain, and analgesic use were not assessed.

Pain was assessed immediately after intranasal midazolam administration by self-report with the 10-point Wong-Baker FACES Pain Scale. Median pain was 3 with lidocaine vs. 8 with saline (p = 0.006), and pain was rated at ≤ 2 points in 50% vs. 28% (statistical comparison not reported). Also, 15% of the children who had lidocaine rated their pain at 10 (the corresponding number of patients in the saline group was not reported). Other outcomes, such as anxiety assessments or adverse events, were not reported.

This trial demonstrates that pretreatment with intranasal lidocaine may reduce pain associated with intranasal midazolam in children having procedural sedation. Several limitations temper the results. Lidocaine did not eliminate extreme pain in all children, and the results cannot be generalized to patients who are not 6-12 years old or who have more severe conditions. Also, since baseline anxiety levels, pain, and analgesic use were not assessed, the possibility that these variables influenced reported pain cannot be eliminated. Finally, this trial did not assess the effect, positive or otherwise, of lidocaine on anxiety levels or procedure quality. Overall however, based on this trial, pretreatment with intranasal lidocaine appears to be a simple and effective method for improving tolerability to intranasal midazolam.

See the Procedural sedation and analgesia topic in DynaMed Plus for more information.


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