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PubMed1991

Carbidopa-levodopa overdose.

A 57-year-old woman ingested 15 to 17 tablets of carbidopa-levodopa 10/100 tablets (carbidopa 150 mg and levodopa 1,500 mg) along with ibuprofen, carisoprodol, hydrocodone, and acetaminophen. The patient developed choreiform movements that persisted despite obtundation and attempts to extinguish them with naloxone, morphine, and diazepam. When the patient developed a rising level of creatine phosphokinase and myoglobinuria, she was treated with ventilatory support and pancuronium. She required paralysis for 60 hours, when her chorea resolved.

Acetaminophen↗
PubMed1984

Combination analgesics.

Six rationales for using combination analgesics are identified, but most combinations are formulated with two rationales in mind: enhancement of analgesia and reduction of adverse effects by combining two analgesics with different mechanisms of action. Acetaminophen and aspirin are the mainstays of oral analgesic combinations. There is substantial evidence that combining an optimal dose of acetaminophen or aspirin with an oral opioid such as codeine, hydrocodone, or oxycodone produces an additive analgesic effect greater than that obtained by doubling the dose of either constituent administered alone. There is also some evidence that the adverse effects produced by such combinations are less than would be produced by an equi-analgesic dose of a single constituent. The physician need not be confined to existing fixed-ratio combinations; he or she may extemporize to the patient's advantage by co-administering acetaminophen, aspirin, or other nonsteroidal anti-inflammatory drugs with available oral opioids and, in select situations, co-administering oral or injectable analgesics with psychoactive drugs.

Acetaminophen↗
PubMed2002

A double-blind, single-dose comparison of the analgesic efficacy of tramadol/acetaminophen combination tablets, hydrocodone/acetaminophen combination tablets, and placebo after oral surgery.

BACKGROUND: Improved clinical outcomes have been documented with combinations of oral analgesic agents, particularly those with complementary activities. However, because not all combinations or dose ratios lead to enhanced analgesia or reduced adverse events (AEs), each combination and dose ratio must be evaluated individually in carefully designed preclinical and clinical trials. OBJECTIVE: The goal of the study was to compare the efficacy and safety of 37.5 mg tramadol/325 mg acetaminophen tablets (T/APAP), 10 mg hydrocodone bitartrate/650 mg acetaminophen tablets (HC/APAP), and placebo in the treatment of postoperative dental pain. METHODS: This was a single-center, double-blind, parallel-group, placebo- and active-controlled study in adults with at least moderate pain (score > or =50 on a 100-mm pain visual analog scale) after extraction of > or =2 impacted third molars. Patients were randomized to receive 1 or 2 T/APAP tablets, 1 HC/APAP tablet, or placebo. Scores for hourly pain relief (PAR), pain intensity difference (PID), and combined PAR and PID (PRID) were based on reported pain at 30 minutes and each successive hour for 8 hours. Primary efficacy measures were summary pain intensity and pain relief scores (total pain relief [TOTPAR], sum of pain intensity differences [SPID], and sum of pain relief and pain intensity differences [SPRIDI) for 0 to 4 hours, 4 to 8 hours, and 0 to 8 hours. Secondary efficacy measures were hourly PAR, PID, and PRID scores; onset and duration of pain relief; time to remedication with a supplemental analgesic agent; and patients' overall assessment of medication. RESULTS: Two hundred adults took part in the study (50 per treatment group) and were included in the efficacy and safety analyses. T/APAP 75/650 mg and HC/APAP were statistically superior to placebo on the primary efficacy measures of TOTPAR, SPID, and SPRID (P < or = 0.024), as well as on hourly PAR, PID, and PRID over 6 hours (P < or = 0.045). All active treatments were statistically superior to placebo in terms of onset of pain relief (P < or = 0.001), duration of pain relief (P < or = 0.024), time to remedication (P < 0.001), and patients' overall assessment of medication (P < 0.001). A statistically significant dose response with T/APAP (2 tablets > 1 tablet > placebo) was seen for TOTPAR, SPID, and SPRID (all, P < or = 0.018). The median time to onset of pain relief was approximately 34.0 minutes with 2 T/APAP tablets and 25.4 minutes with HC/APAP. Although the median time to onset of pain relief was shorter with HC/APAP, two T/APAP tablets had comparable efficacy to HC/APAP. The median time to remedication with a supplemental analgesic agent was 169.0 minutes in the T/APAP 75/650 mg group and 204.0 minutes in the HC/APAP group. However, the duration of pain relief, as defined by time to remedication, was not significantly different between these 2 groups. The overall incidence of AEs was lower with T/APAP (0% treatment-related AEs) than with HC/APAP (4%) or placebo (10%). The incidence of nausea (18% T/APAP, 36% HC/APAP) and vomiting (12% T/APAP, 30% HC/APAP) was approximately 50% lower with 2 T/APAP tablets than with HC/APAP (P < 0.05). CONCLUSIONS: T/APAP tablets provided effective, rapid (< or = 34 minutes), dose-dependent analgesia for the treatment of postoperative dental pain. Two T/APAP tablets provided analgesia comparable to that provided by HC/APAP with better tolerability.

Acetaminophen↗
PubMed1998

Fatal opiates overdose. Toxicological identification of various metabolites in a blood sample by GC-MS after silylation.

A fatal opiates overdose, where ethylmorphine, hydrocodone, dihydrocodeine and codeine were consumed concomitantly, is reported. This case report may contribute to data on fatal blood concentrations of drugs with rare incidence. The relative retention times in capillary gas chromatography and full mass spectra of various opiates in their silylated forms, detected together in one sample, may serve as a helpful analytical reference for clinical and forensic toxicologists.

Adult↗
PubMed1999

Distinction among eight opiate drugs in urine by gas chromatography-mass spectrometry.

Opiates are commonly abused substances, and forensic urine drug-testing for them requires gas chromatographic-mass spectrometric (GC-MS) confirmation. There are also medical reasons to test urine for opiates, and confirmation procedures other than GC-MS are often used for medical drug-testing. A thin-layer chromatographic (TLC) method distinguishes morphine, acetylmorphine, hydromorphone, oxymorphone, codeine, dihydrocodeine, hydrocodone, and oxycodone in clinical specimens. In certain clinical circumstances, GC-MS confirmation is requested for opiates identified by TLC, but, to our knowledge, no previous report examines all of the above opiates in a single GC-MS procedure. We find that they can be distinguished by GC-MS analyses of trimethylsilyl (TMS) ether derivatives, and identities of 6-keto opiates can be further confirmed by GC-MS analysis of methoxime (MO)-TMS derivatives. Inclusion of deuterium-labeled internal standards permits identification of the opiates in urine at concentrations below the TLC cutoff level of 600 ng/ml, and the GC-MS assay is linear over a concentration range that spans that level. This GC-MS procedure has proved useful as a third-stage identification step in a medical drug-testing sequence involving prior immunoassay and TLC.

Codeine↗
PubMedDate not supplied

Preoperative intra-articular morphine and bupivacaine for pain control after outpatient arthroscopic anterior cruciate ligament reconstruction.

BACKGROUND AND OBJECTIVES: The purpose of this study was to determine whether intra-articular injection of bupivacaine, morphine, or a combination prior to surgery provided pain control after arthroscopic anterior cruciate ligament (ACL) reconstruction. METHODS: These data were collected as a two-stage prospective, randomized, blinded observer study. All patients received a standard general anesthetic, which included an intra-articular injection 20 minutes prior to incision. In phase I, three solutions were assigned randomly in a 60-mL volume. Group 1 was saline, group 2 was 0.25% bupivacaine, and group 3 was 0.25% bupivacaine with 1 mg morphine sulfate (MS). Phase II was identical to phase I in technique and had four groups. Group 1 was 0.25% bupivacaine, group 2 was 1 mg MS in saline, group 3 was 0.25% bupivacaine with 1 mg MS, and group 4 was 0.25% bupivacaine with 3 mg MS. All groups in phases I and II contained 1:200,000 epinephrine, freshly added. Pain scores were evaluated at 0, 30, 60, 90, 120, and 240 minutes postoperative using a visual analog scale. For pain scores of 5 or greater, 50 microg fentanyl was administered at 5-minute intervals until pain was controlled. After transition from phase I to phase II of the postanesthesia care unit (PACU), hydrocodone/acetaminophen tablets were used. RESULTS: Thirty patients were entered into phase I of the study. Both treatment groups (2 and 3) had significant (P < .05) pain reduction on arrival to the PACU. Group 3 had significantly (P < .05) reduced need for fentanyl during the PACU stay. Forty-nine patients entered phase II of the study. In phase II, group 3 had the lowest pain scores on arrival to the PACU. At 120 and 240 minutes, pain scores were lower in groups 3 and 4. Fentanyl and hydrocodone uses were significantly lower during the PACU stay in groups 3 and 4. CONCLUSIONS: Presurgical injection of a solution of 0.25 % bupivacaine, morphine, and epinephrine provided pain control and decreased opioid use in the PACU. Increasing the morphine dose did not improve the clinical result.

Acetaminophen↗
PubMed2001

Engineering novel biocatalytic routes for production of semisynthetic opiate drugs.

The morphine alkaloids and their semisynthetic derivatives provide a diverse range of important pharmaceutical drugs. Current production of semisynthetic opiate drugs is by chemical means from naturally occurring morphine, codeine and thebaine. Although various microbial transformations of morphine alkaloids have been identified since the 1960s, more recently there has been considerable effort devoted to engineering biocatalytic routes for producing these important compounds. Such biocatalytic routes are attractive, as they would provide an alternative to the chemical production processes which suffer from limited supply of precursors, often low yields and toxic wastes. The biotransformation of morphine and codeine to the potent analgesic hydromorphone and the mild analgesic/antitussive hydrocodone, respectively, by recombinant Escherichia coli has been demonstrated and the problems encountered when engineering such a system will be discussed.

17-Hydroxysteroid Dehydrogenases↗
PubMed1995

Biological production of semisynthetic opiates using genetically engineered bacteria.

Semisynthetic derivatives of morphine and related alkaloids are in widespread clinical use. Due to the complexity of these molecules, however, chemical transformations are difficult to achieve in high yields. We recently identified the powerful analgesic hydromorphone as an intermediate in the metabolism of morphine by Pseudomonas putida M10. Here we describe the construction of recombinant strains of Escherichia coli that express morphine dehydrogenase and morphinone reductase. These strains are capable of efficiently transforming the naturally occurring alkaloids morphine and codeine to hydromorphone and the antitussive hydrocodone, respectively. Our results demonstrate the potential for recombinant DNA technology to provide biological routes for the synthesis of known and novel semisynthetic opiate drugs.

Alcohol Oxidoreductases↗
PubMed2005

Continuous intra-articular infusion of bupivacaine for postoperative pain following total knee arthroplasty.

This study assessed the efficacy of local, continuous infusion of bupivacaine for pain control following total knee arthroplasty. Eleven men and 19 women with an average age of 65 years (range: 43-83 years) randomly received either 0.25% bupivacaine or normal saline by local infusion pump. Standard wound drainage also was implemented. Pain was assessed with a visual analog scale along with patient-controlled analgesia demand, narcotic delivery, and nonsteroidal anti-inflammatory administration. Drug lost to drainage also was assessed. Mean preoperative visual analog scores were similar between the saline and bupivacaine groups (6.5 +/- 1.4 and 6.1 +/- 2.0, respectively; P = .535). By the end of the second postoperative day, scores decreased to 3.4 +/- 3.2 for the saline group and 2.5 +/- 1.6 for the bupivacaine group. Although postoperative reductions were statistically significant (P = .007), the main treatment effect was not (P = .404). Mean narcotic demand and usage were 87 +/- 114.1 requests with usage of 11.8 +/- 12.3 mg for the saline group and 96 +/- 104.8 requests with usage of 7.5 +/- 3.8 mg for the bupivacaine group (P = .505). Cumulative ketorolac administration was 47 +/- 52.2 mg for the saline group and 83.6 +/- 64.9 mg for the bupivacaine group (P=.100). Hydrocodone-acetaminophen usage also was similar between the saline and bupivacaine groups (88 +/- 43.9 mg and 64.6 +/- 35 mg, respectively) (P = .112). Drug lost to drainage was estimated to be 27%. These findings suggest continuous local analgesic infusion after total knee arthroplasty does not offer significant improvements in either pain relief or medication use. Drug loss from drainage may exceed 25% and may compromise analgesic effectiveness.

Acetaminophen↗
PubMed2001

[Does the inhalation of a 1% L-menthol solution in the premedication of fiberoptic bronchoscopy affect coughing and the sensation of dyspnea?].

BACKGROUND: Inhalation of l-menthol inhibits cough and has been shown to reduce respiratory discomfort associated with loaded breathing. We investigated the effect of the inhalation of a 1% l-menthol solution in the premedication of fiberoptic bronchoscopy (FB) on the frequency of cough and the irritability of the tracheobronchial mucosa during FB in a blinded, randomized and placebo controlled study. METHODS: 64 pat. (30-78 yrs, 55 males) underwent routine FB. Premediction: atropine and hydrocodone s.c., inhalation of oxybuprocain by means of a jet nebulizer, sedation on demand. Verum-group: inhalation of 3 ml 1% l-menthol-solution. Placebo-group: 3 ml 0.05% l-menthol (to provide the typical smell). Before and after inhalation peak respiratory flow (PEF) was registered, during FB the frequency of cough was measured. The bronchoscopist scored the irritability of the tracheobronchial mucosa using a visual analog scale. The patients answered a questionnaire addressing their perception of dyspnea and cough on the day after FB compared to the day before. RESULTS: The cough counts didn't show a significant difference between the groups. The irritability of the mucosa was increased in the verum group (main bronchus verum 62.2 +/- 22, placebo 48.6 +/- 23 [mm vissual analog scale, p = 0.03]). Cough and dyspnea reported by the patients decreased on the day after FB significantly compared to the day before (no difference between the groups). The inhalation of 1% l-menthol induced a significant increase of the PEF (verum 307 +/- 103 pre, 329 +/- 84 post [l/min, p = 0.003]) compared to placebo. CONCLUSIONS: The inhalation of 1% l-menthol did not enhance the tolerability of the FB. However, l-menthol induced a significant increase of the PEF immediately after inhalation. Finally sensation of dyspnea was decreased in both groups at the day post FB.

Administration, Inhalation↗
PubMed1995

Facilitation of thin-layer chromatographic identification of opiates by derivatization with acetic anhydride or methoxyamine.

Qualitative identification of opiates in urine is commonly achieved in two stages, the first involving immunoassay screening and the second involving chromatographic confirmation. Identification of specific opiates is often requested to determine whether the source of opiates is from diet, prescription pharmaceuticals, or illicit drugs. During evaluation of the Toxi-Lab thin-layer chromatographic system as a confirmatory technique for urinary opiates, we encountered difficulty distinguishing opiates with similar retention factor values and colorimetric behavior. By exploiting chemical differences of the comigrating opiates through preparation of acetate or methoxime derivatives, followed by chromatography of the underivatized and derivatized samples in adjacent lanes, we were able to more easily distinguish codeine from hydrocodone, 6-acetylmorphine from oxymorphone, and dihydrocodeine from hydromorphone.

Acetic Anhydrides↗
PubMed1995

Zolpidem tissue concentrations in a multiple drug related death involving Ambien.

Zolpidem (Ambien), a relatively new nonbenzodiazepine sedative-hypnotic, was involved in the death of a 39-year-old obese male who was being treated for depression and insomnia. The identification and quantitation procedures of zolpidem in postmortem tissues included dual-column gas chromatography (GC) with nitrogen-phosphorus detection and GC-mass spectrometry. Zolpidem was present at concentrations of 2.91, 1.40, and 2.13 microg/mL in the heart blood, peripheral blood, and urine, respectively. The liver had zolpidem present at a concentration of 4.74 microg/g, and the gastric contents had a total of 172 mg zolpidem. Additional drugs present included hydrocodone and morphine (nonconjugated) at 0.16 and 0.04 microg/mL, respectively. The cause of death was determined to be multiple drug intoxication. This report describes the analytical techniques and significance of the zolpidem findings.

Administration, Oral↗
PubMedDate not supplied

Acetaminophen, aspirin, or Ibuprofen in combination analgesic products.

Pain of multiple etiologies remains a substantial problem for many patients presenting in the clinical setting. Improved pain relief can be demonstrated, and adverse effects minimized, by multimodal analgesic combinations as the method to improve pain treatment. Substantial evidence supports combining analgesics for the management of pain and, in some instances, they have a heterogeneous pharmacologic sparing effect. Fixed-dose combination analgesics with demonstrated efficacy and safety are widely useful for pain management. However, work needs to continue to further explore which analgesics at which doses can be combined with a coanalgesic in a patient-specific manner to achieve additive, if not synergistic, multimodal pain relief with the fewest possible adverse consequences. Unsupervised consumption of over-the-counter drugs that contain acetaminophen, aspirin, or ibuprofen offers clinical challenges to both the patient and health care providers. Couple this often undisclosed over-the-counter medication consumption event with prescription medications, which many contain similar combination ingredients, and the potential for a therapeutic misadventure may precipitate. This article will address the safety and efficacy of acetaminophen, aspirin, and ibuprofen independently and in combination with currently available prescription dosage forms with a focus on pharmacology, pharmacotherapeutics, pharmacodynamics, and pharmacokinetics, including drug interactions at the CYP450 system. Patient-specific cautions are presented for opiate/opioid combinations, codeine, hydrocodone, oxycodone, and propoxyphene, and there is a discussion of COX I/COX II agents.

Acetaminophen↗
PubMed2004

Presurgical intravenous parecoxib sodium and follow-up oral valdecoxib for pain management after laparoscopic cholecystectomy surgery reduces opioid requirements and opioid-related adverse effects.

BACKGROUND: Opioids are associated with numerous adverse effects. It is unclear if reduced postoperative opioid consumption lowers the incidence and severity of opioid-related adverse effects. This analysis -- from a multicenter, randomized, double-blind trial -- tested if the reduction of opioid consumption among patients who received intravenous preoperative parecoxib 40 mg, followed by oral valdecoxib 40 mg qd postoperatively, in Days 1-4 after outpatient laparoscopic cholecystectomy surgery, reduced opioid-related symptoms. METHODS: Patients received intravenous fentanyl for pain before discharge, and oral acetaminophen 500 mg hydrocodone 5 mg q 4-6 h prn postdischarge for up to 7 days postsurgery. Patients also received intravenous parecoxib 40 mg administered 30-45 min preoperatively, and valdecoxib 40 mg qd up to Day 4 and prn Days 5-7 postsurgery, or placebo. Patients completed an opioid-related Symptoms Distress Scale (SDS) questionnaire every 24 h for 7 days. Opioid use was converted to morphine-equivalent doses (MEDs). Clinically meaningful events (CMEs) for 12 opioid-related symptoms were assessed by three ordinal measures: frequency, severity, and bothersomeness. Reduction of CMEs on Day 1 and number of patient-days with CMEs on Days 1-4 were examined. RESULTS: Cumulative MEDs on Day 0, Day 1, and Days 1-4 were significantly lower in the parecoxib/valdecoxib group compared with the placebo group (P < 0.001). At the end of Day 1, parecoxib/valdecoxib-treated patients had significantly lower SDS scores (P < 0.02), a significantly reduced incidence of CMEs (P < 0.05), and significantly fewer patient-days with CMEs in Days 1-4 than placebo patients (P < 0.05). Patients in the parecoxib/valdecoxib group were less likely to have CMEs for multiple symptoms than those in the placebo group (P < 0.001). CONCLUSIONS: Treatment with parecoxib and valdecoxib significantly reduced the cumulative MED requirements, the incidence of opioid-related adverse effects, and patient-days with CMEs.

Administration, Oral↗
PubMed2006

Continuous femoral nerve block versus intra-articular injection for pain control after anterior cruciate ligament reconstruction.

BACKGROUND: Continuous femoral nerve blocks have been recommended for postoperative pain control after anterior cruciate ligament reconstruction. HYPOTHESIS: A pain control protocol involving a continuous ropivacaine femoral nerve block will decrease pain and narcotic use in the first 24 hours after surgery compared with a postoperative pain control protocol involving an intra-articular injection of bupivacaine/morphine. STUDY DESIGN: Randomized controlled clinical trial; Level of evidence, 2. METHODS: Ninety subjects, aged 15 years or older, who were receiving arthroscopically assisted bone-patellar tendon-bone anterior cruciate ligament reconstruction were randomly assigned to 2 groups. The first group received a ropivacaine continuous femoral nerve block and oral hydrocodone (block group). The second group received an intra-articular bupivacaine/morphine injection and oral oxycodone (injection group). Patients in both groups could receive intramuscular injection of hydromorphone for breakthrough pain; most patients in the block group also received bolus doses of ropivacaine through the femoral catheter. Subjects rated their worst, average, and current pain levels using a visual analog scale and category-ratio scale the morning after surgery. Postoperative narcotic pain medication use was converted to morphine-equivalent doses. RESULTS: Postoperative pain ratings did not differ between the treatment groups. The largest difference in pain ratings between the groups was 0.5 cm for worst pain level (P = .345). Total narcotic use did not differ significantly between groups (1.1 morphine-equivalent doses in both groups; P = .671). CONCLUSIONS: Continuous femoral block with ropivacaine appeared to have no clinical advantage in the immediate postoperative period after anterior cruciate ligament reconstruction when compared with an intra-articular injection of bupivacaine/morphine. Both methods are effective for pain control after anterior cruciate ligament reconstruction.

Administration, Oral↗
PubMed2005

Prescription drug abuse among ecstasy users in Miami.

This study examines the nature, extent and consequences of prescription drug abuse among 143 ecstasy users in Miami. Participants were recruited through nightclub and college campus outreach, and through respondent referrals. Instrumentation included the Risk Behavior Assessment, Substance Abuse Module and Center for Epidemiological Studies Depression Scale. Median age was 23, 42% were female and 50% Hispanic. An arrest history was reported by 44%, and 33% reported prior drug/alcohol treatment. Prescription drug abuse was reported by 87%; alprazolam (57%), oxycodone (36%), hydrocodone (32%) and diazepam (30%) were cited most often. Prescription drug abusers were more likely to report polydrug use, drug treatment histories, risky drug use behaviors, and symptoms of depression. They also reported numerous physical, psychological and social consequences of prescription drug abuse. Additional studies among larger samples are needed to understand the processes of prescription drug access and the extent of integration in club drug using cultures.

Adolescent↗
PubMed2005

Detection of hypoventilation during thoracoscopy: combined cutaneous carbon dioxide tension and oximetry monitoring with a new digital sensor.

BACKGROUND: Changes in Paco(2) have not been described during thoracoscopy under sedation-assisted local anesthesia. We hypothesized that hypoventilation might occur secondary to administration of sedatives and decreased ventilation in one lung. AIM: Prospectively measure cutaneous carbon dioxide tension (Pcco(2)) in addition to pulse oximetric saturation (Spo(2)) using a new combined digital sensor to examine the occurrence of hypoventilation during thoracoscopy under sedation-assisted local anesthesia. SETTING: University hospital. METHODS: Following validation studies, Pcco(2) was prospectively measured in 16 consecutive patients undergoing thoracoscopy under sedation-assisted local anesthesia using a combined digital earlobe sensor measuring Spo(2) (percentage) and Pcco(2) (millimeters of mercury). All patients received supplemental oxygen. Routine BP monitoring and Spo(2) was continued. Patients received IV hydrocodone, 5 mg, and intermittent boluses or IV midazolam and pethidine. RESULTS: Mean baseline Pcco(2) measurement was 39.1 +/- 7.2 mm Hg (+/- SD) [range, 27.5 to 50.5 mm Hg], and peak measurement during the procedure was 52.3 +/- 10.3 mm Hg (range, 37.2 to 77 mm Hg) [p < 0.001]. Median and mean changes in Pcco(2) measurement from baseline were 13.0 mm Hg and 13.2 +/- 5.3 mm Hg (range, 5.5 to 27.8 mm Hg), respectively. Mean fall in Spo(2) during the procedure was 4.6 +/- 3.2% (range, 1 to 14%). CONCLUSIONS: Thoracoscopy performed under sedation-assisted local anesthesia is associated with significant hypoventilation. Combined measurement of Spo(2) and Pcco(2) during thoracoscopy is a novel approach in the monitoring of ventilation, enhancing patient safety, and might allow to guide the administration of sedation in a better way.

Adult↗
PubMed2005

Nebulized lidocaine for flexible bronchoscopy: a randomized, double-blind, placebo-controlled trial.

OBJECTIVE: Topical anesthesia for flexible bronchoscopy can be administered via transcricoid injection, nebulizer, or directly through the bronchoscope in a "spray as you go" fashion. We performed a prospective, randomized, double-blind, placebo-controlled trial to evaluate whether nebulized lidocaine provides additional benefit and reduces the total anesthetic dose required during bronchoscopy. SETTING: Tertiary care university hospital. METHODS: One hundred fifty patients (93 men; age, 20 to 89 years) undergoing diagnostic flexible bronchoscopy were randomized to receive either 4 mL of 4% lidocaine (160 mg) or 4 mL of saline solution as placebo via nebulization. Combined sedation was achieved using 5 mg of IV hydrocodone and midazolam boluses. Supplemental lidocaine doses and total midazolam required as judged by the bronchoscopist were recorded for each patient. After the procedure, both bronchoscopists and patients charted their perception of cough on a 10-cm visual analog scale (VAS). Similarly, patients recorded their discomfort related to the procedure on a 10-cm VAS. RESULTS: The most common procedures were BAL in 77 cases (51%), transbronchial biopsy in 40 cases (27%), and transbronchial needle aspiration in 34 cases (23%). Outcome parameters, including hemodynamic findings, duration of the procedure, cough scores for physicians and patients, discomfort score for patients, midazolam doses, and supplemental lidocaine doses, were similar in both groups. Mean total lidocaine dose required in the lidocaine group was 318 +/- 41 mg and was significantly higher than the total dose required in the placebo group (157 +/- 44 mg [+/- SD]) [p < 0.001]. CONCLUSION: Additional nebulized lidocaine cannot be recommended for flexible bronchoscopy performed under combined sedation.

Administration, Inhalation↗