Consensus recommendations for paediatric airway topicalisation using lidocaine
Anaesthesia
Submitted January 2026 by Dr Roeland Passier
Read by 13 Journal Watch subscribers
Summary
This systematic literature review, followed by a three-round Delphi process, was conducted by an international expert multidisciplinary, multi-society working group. It produced consensus recommendations for paediatric airway topicalisation using lidocaine with the aim to improve the safety of this procedure.
The working group was formed and the systematic review of the literature performed to inform the recommendations in accordance with the principles of the AGREE and the PRISMA reporting checklists. The working group consisted of 24 representatives of various relevant societies and stakeholders. The initial process identified 26 articles, the results of which were subsequently used in a three-round Delphi study to formulate 21 recommendations across 5 domains of practice: dosing, recovery, adverse reactions, institutional responsibilities and learning from events. These recommendations were based on a number of factors including strength of evidence, applicability to clinical practice, multidisciplinary team involvement and practical implications.
Recommendations were graded A to D according to the strength of the available evidence and were found to be mainly C and D. The strength of recommendations judgements were graded strong (S), moderate (M) or weak (W) based on the analysis of the evidence, consensus voting and discussion through the Delphi process and were found to be mainly strong or moderate.
Recommendations included:
Dosing
- The age and weight (using ideal body weight (IBW)), concentration of solution and volume should all be taken into account when considering dosing of topical lidocaine for airway procedures (grade B, S).
- A maximum dose of 5 mg /kg may be considered safe, however more conservative doses are often effective and advised. A maximum dose of 4 mg /kg IBW is recommended if children are < 6 months, underweight or have hepatic disease.
- Two hours after the initial dose an additional dose up to 2.5 mg /kg IBW may be given. (all grade C,S).
- The maximum dose should be discussed at the pre-operative team brief (grade D,S).
- Lidocaine solutions > 4% should not be used (grade D, S), nor should solutions containing adrenaline (grade C, S)
- In children < 10 kg lidocaine 1% or 2% is recommended (grade D, M).
Recovery
- Total dose used, timings of administration (grade D, S) and time from which the child can recommence oral intake should be documented and handed over (grade D, M)
- Children should be fasted for at least 1 hour after airway topicalization, potentially longer when deemed to be at higher risk of aspiration (grade C, S)
- A period of observation should take place with nursing staff aware of signs or symptoms of aspiration and local anaesthetic systemic toxicity (LAST) (grade D,S).
Adverse reactions, institutional responsibilities and learning from events
- Adverse reactions believed to be secondary to lidocaine topicalisation should be reported and parents or guardians should be informed (grade D, S)
- 20% iv lipid emulsion should be immediately available (grade C,S). Departments should have a standard operating procedure or local guideline which is reviewed regularly and updated in line with emerging evidence. They should also regularly conduct multidisciplinary simulation training covering the management of LAST
- Shared learning from adverse events is encouraged e..g. in morbidity and mortality meetings and national database reporting (all grade D,S).
Commentary
There is a paucity of evidence, and lack of other consensus recommendations or (inter)national/ societal guidelines available on the use of lidocaine for airway topicalisation in children, despite it being common practice in paediatric anaesthesia. A recent international study showed heterogeneity in practice globally and evidence of patient harm, signalling a need for more evidence and consensus.
The aim of this study was to establish a safe and pragmatic framework to support clinical practice. The use of lidocaine in this setting is common in Australian and New Zealand practice as well, and there don’t seem to be many surprising or unexpected recommendations.
Some or all of the recommendations likely reflect current practice in most paediatric hospitals in our countries. Nevertheless this is the first time they are actually concurrently listed and backed by a broad group of experts, including representatives from both these countries and by the best available evidence. The recommendations are practical and could be implemented in our health care systems without major issues or obstructions if not yet in place, with the exception of regular multidisciplinary simulation training which potentially might be harder to implement.
Significant gaps in the current literature limit the strength of evidence supporting the recommendations. In general these are largely based on expert opinion, where the dosing recommendations were also informed by pharmacokinetic studies, although these mostly relate to intravenous administration. They purposely have a conservative approach to dosing and repeat dosing. This creates additional safety but potentially unnecessarily limits the maximum available amount that can be given, which might be problematic for longer or more stimulating procedures or younger children.
The authors note a few additional limitations of their study, including the decision not to consider use of adjuncts (such as glycopyrronium, which might influence the rate of adsorption) and not differentiating between awake, sedated and anaesthetised patients. Sedative and anaesthetic drugs such as propofol have the potential to mask some of the early signs and symptoms of LAST. This should not change the maximum amount of lidocaine that can be given but could have caused (early) signs of LAST not to be noted and reported in studies used in this review. Other factors which may be of relevance that are not discussed include the mode of delivery of the lidocaine, type of ventilation, and the surgical procedure itself. However, it would probably be unclear from the available evidence whether these factors influence the maximum dose of lidocaine that can be safely given.
As is often the case, the need for further research in this area is highlighted. Overall, the study provides a practical and well founded set of recommendations for how to increase the safety and decrease the risk of side effects and complications of paediatric airway topicalisation using lidocaine, a common procedure in paediatric anaesthesia practice.
