Improving Lidocaine Topicalisation Practices in Paediatric Airway Management: A Quality Improvement Project

Background Topical lidocaine is routinely used on paediatric vocal cords in surgeries requiring intubation or open airway procedures to suppress reflexes and coughing. Internationally and at University Hospital Southampton (UHS), a lack of standardised technique among anaesthetists has led to complications, including a case of toxicity, and confusion among recovery staff. This quality improvement (QI) project aimed to assess and improve practice against the recognised guidelines. Methods An anonymous questionnaire was distributed to consultant paediatric anaesthetists at UHS to document maximum lidocaine dosage (mg/kg), concentration (%), nil-by-mouth (NBM) time (minutes), administration device and respondents' reported incidents. The findings were then presented to respondents at an educational meeting, and guidelines were advocated to promote standardisation. Two weeks later, an identical follow-up questionnaire assessed changes in practice. Results Thirty-two participants were invited to participate in each survey. Surveys 1 and 2 received 22 (68.8%) and 15 (46.9%) responses, respectively. Median maximum dosages did not differ from the guidelines (4.0 mg/kg): 3.0 mg/kg (range 2.0-9.0 mg/kg, p=0.564) and 4.0 mg/kg (range 2.0-9.0 mg/kg, p=0.483). The distribution was unchanged across surveys (p=0.680), but adherence to guideline dosage increased from 2/22 (9.1%) to 8/15 (53.3%) (p=0.006). Median NBM time in Survey 1 was 120 minutes (range 60-360 minutes), significantly exceeding the guidelines (p<0.001), but decreased to 60 minutes (p=0.066, range 60-300 minutes), aligning with guidelines, and adherence improved from 8/22 (36.4%) to 11/15 (73.3%) (p=0.045). The choice of administration device was unchanged (p=0.850). No respondents reported using a lidocaine concentration above the recommended 4%. The 95% confidence intervals were calculated for the estimates. Discussion Substantial variation was identified in consultant anaesthetists' practice regarding this technique, consistent with findings from national and international surveys. Following the intervention, the median dosage remained aligned with the recommended guidance of 4.0 mg/kg, but adherence increased significantly. In contrast, reported NBM times showed marked deviation from the recommended standard of 60 minutes, with excessive NBM times commonly being used. Post-intervention, both median NBM time and the proportion of respondents adhering to the standard improved substantially, although heterogeneity persisted. The choice of administration device was unchanged. This QI demonstrates that simple educational interventions can improve adherence to airway topicalisation standards and may inform similar local QI projects in other institutions where practice variability remains unidentified.