Clinical Question y Does administration of nebulized lidocaine (lignocaine) before nasogastric tube (NGT) insertion reduce patient discomfort?
Citation y Nebulised lidocaine before nasogastric tube insertion reduced patient discomfort but increased risk of nasal bleeding Study Characteristics a. Patients Included y 50 patients .18 years of age (50% men) who required a NGT as part of their ED treatment. b. Interventions compared y lidocaine, 400 mg, 4 ml of 10% solution (n = 29) or normal saline solution (n = 21) administered using a face mask and a compressed gas powered jet nebuliser (Hudson Respiratory Care Inc, Temecula, CA) with an oxygen flow rate of 6 l/min. Immediately after nebulisation, the nurse removed the mask and inserted the NGT (18F Salem sump tube, Sherwood Medical, St Louis, MO) with KY Jelly lubrication gel. Tube placement was confirmed by auscultation, aspiration of gastric contents, or radiographic identification. The other intervention was through the use of a placebo and inserting the Nasogastric Tube c. Outcomes monitored y Outcomes: patient discomfort during insertion of NGT (100 mm visual analogue scale), difficulty of NGT insertion as assessed by the nurse (5 point Likert scale), and complications (eg, nasal bleeding, vomiting, or failed passage of tube). d. Does the study focus on a significant problem in clinical practice? y The study focuses on a significant problem in the clinical practice because we all know that NGT insertion is a very discomforting experience to our patients. Thus this study focuses on creating a new type of intervention that will make NGT insertion to patients more comfortable and easier also for health care persons to carry out NGT insertion. Methodology/Design a. Methodology used y Experimental Methodology b. Design y randomized, placebo controlled trial c. Setting y emergency departments (EDs) of 2 large university hospitals in Australia.
but the groups did not differ for vomiting. No allergy lidocaine.100 mm Hg. weight is >50 kg. y V.50 kg. No pre-existing gag reflex impairment.Nurses perceived difficulty of tube insertion did not differ between groups (table). Data sources y ebn. systolic blood pressure . vomiting and chest tightness or dyspnea to the patients when nebulized lidocaine was done before NGT insertion. Subject selection ( inclusion and exclusion) y Inclusion criteria were patients who require NGT insertion.
Table of Test Result
Outcome Patient discomfort (mean visual analogue scale score in mm) Nurses perceived difficulty of tube insertion (median score)`
Lidocaine 37. But the benefits tested in this study was it showed a significant decrease in the discomfort level and showed easy access of the NGT insertion to the patients who were given the nebulized lidocaine intervention compared to those who were on the placebo intervention. f. Exclusion criteria were inability to assess pain (altered mental state. pregnancy.Published by group. or reactive airways disease. language barrier. inability to pass the NGT. whereas compared to the placebo intervention none of those were reported.7 2
Placebo 59.bmj. No concurrent administration of intravenous lidocaine. concurrent administration of intravenous lidocaine. 2010 .0) 0 (-1 to 1)
.com on July 7. major trauma).bmj. More patients who received nebulized lidocaine had nasal bleeding. or dementia). allergy to lidocaine. pre-existing gag reflex impairment.com e. or chest tightness and dyspnea (table). Results of the Study y Patients who received nebulized lidocaine reported less discomfort during NGT insertion than patients who received placebo (table).6% (5. or reactive airways disease. emergency indication for NGT insertion (eg.d. Has the original study been replicated? y The study is replicated g.3 2
Difference (95% CI) 21. Not pregnant. What were the risks and benefits of the nursing action tested in the study? y The risks of the nursing action tested in this study is that there were indicated reports of nasal bleeding.3 to 38. weight .
randomised. Although desired outcome was least achieved but the study provided clinical evidence of outcome to be monitored if this type of intervention will be used to patients requiring NGT insertion. More patients who received nebulised lidocaine developed nasal bleeding.4% 0 Inability to pass tube 6. This double blind. _100 mm scale.5 to 31) 10%(20. Also thorough assessment and history should be taken into important consideration before doing the procedure.
17%(3.2 3 What is standard practice? None of 10 major
. they did not discuss the potential effect of the 14 year median age difference between the 2 groups.
Author s conclusion/Recommendation y Nebulised lidocaine reduced patient discomfort more than placebo during nasogastric tube insertion in the emergency department. Is it feasible to carry out the nursing action in the real world? This study will not be directly feasible to carry out in the real world because the interventions in the study require a doctor s consent before carrying it out. where 0 = no discomfort and 100 = severe discomfort. However.Nasal Bleeding 17% 0 Vomiting 10% 0 Chest tightness 3. where 1 = minimal difficulty and 5 = extreme difficulty. and 10% vomited after lidocaine administration (although the latter was not significantly different from placebo). Reviewer s conclusion/ commentary
VIII. Caution is therefore advised when using this method for delivering topical lidocaine.2 to 10) -2.
Patients report that NGT insertion is a very painful procedure. with no difference in nurse assessed ease of tube insertion. placebo controlled trial was well designed overall. VI. The authors highlighted some limitations. Atomised lidocaine and lidocaine gel before NGT placement have been shown to reduce discomfort without these unwanted side effects. even worse than abscess drainage or urethral catheterisation. b. Does the study provide direct enough answer to your clinical question in terms of type of patients.1 The trial by Cullen et al investigated the use of nebulised lidocaine before NGT insertion and found significant reductions in patient discomfort during tube insertion. Applicability a. such as the unit of analysis error. Patients who received nebulised lidocaine were more likely to have nasal bleeding. intervention and outcomes? The study sufficiently provides answer to the clinical question in terms of patients. which would have required cluster analysis to determine if outcomes differed by the nurse doing the insertion. `5 point Likert scale.6%(-18 to 10)
VII.4% (-3.9% 9.7 to 21) 3.5% *CI defined in glossary. interventions and outcomes.
BN(Hon). 2 Wolfe TR. However. Matheson K. Kowalska A. Ann Emerg Med 1999. J Clin Nurs 1999.Emil Schmidt. Wilson S.
. Practitioners also describe using various comfort strategies when preparing and inserting NGTs. J Emerg Nurs 2003. 4 Penrod J. data from studies comparing lidocaine delivery by nebulisation or atomisation or as a topical gel are needed before recommendations about mode of delivery can be included in practice guidelines. However. ICU Reg Dunedin Hospital. Dunedin. Linscott MS.8:31 8.4 Topical anaesthetics can complement these important comfort strategies. Fosnocht DE.nursing journals surveyed (eg. polling of experienced practitioners revealed use of topical lidocaine gel sometimes but not as standard practice. Ann Emerg Med 2000. Richman PB.29:427 30. New Zealand. 3 Ducharme J. et al. Morse JM. Nurs Stand) recommend topical lidocaine in their NGT insertion guidelines. RN.35:421 5.33:652 8. 1 Singer AJ.