Letters to the Editor

and dead space gas makes these measurements unre- cycle. These additional findings will confirm that the
liable in practice and likely accounts for this 90%
recommendation.2 A more realistic and attainable
goal for preoxygenation should be an EtO2 in the mid
80's. We should always know what the limitations are
as we perform the simple task of preoxygenation.
Amir Tulchinsky, MD
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Eto2 values more closely represent alveolar gas rather
than fresh O2 inflow or dead space gas. It is important
to strive for an Eto2 of 90% acknowledging inaccuracies
that may be observed clinically as a function of the gas
sampling methodologies. In the context of the above
considerations, attempting to achieve a 90% Eto2 goal
is a reasonable target when attempting to maximally

Department of Anesthesiology preoxygenate the physiologically difficult airway.

University of Connecticut Health Center
Farmington, Connecticut Rebecca L. Kornas, MD
tulchinsky@uchc.edu Department of Emergency Medicine
REFERENCES
Denver Health
Denver, Colorado
1. Kornas RL, Owyang CG, Sakles JC, Foley LJ, Mosier
JM; Society for Airway Management’s Special Projects Clark G. Owyang, MD
Committee. Evaluation and management of the physi- Department of Medicine
ologically difficult airway: consensus recommendations Division of Pulmonary and Critical Care Medicine
from Society for Airway Management. Anesth Analg. NewYork-Presbyterian/Weill Cornell Medicine
2021;132:395–405. New York, New York
2. Benumof JL, Herway ST. High end-tidal oxygen concentra- clark.owyang@gmail.com
tion can be a misleading sole indicator of the completeness John C. Sakles, MD
of preoxygenation. Anesth Analg. 2017;124:2093. Department of Emergency Medicine
DOI: 10.1213/ANE.0000000000005572 University of Arizona College of Medicine
Tucson, Arizona
Lorraine J. Foley, MD
Department of Anesthesiology
In Response

W
Winchester Hospital
e appreciate the thoughtful letter of Tufts University School of Medicine
Tulchinsky1 on our recommendation of a Boston, Massachusetts.
goal end-tidal oxygen (Eto2) of 90%.2 As Jarrod M. Mosier, MD
he discusses, the highest fraction of alveolar oxygen Department of Emergency Medicine
(FAO2) that can be achieved with ideal preoxygen- University of Arizona College of Medicine
ation is ~87%. In a closed circuit with side stream Tucson, Arizona
sampling, Eto2 approaches FAO2, and thus, 87% is Department of Medicine
the more accurate goal. However, it is not uncom- Division of Pulmonary, Allergy, Critical Care and Sleep
mon to clinically observe Eto2 above 90% because University of Arizona College of Medicine
the gas analyzer can be contaminated by the 100% Tucson, Arizona
fraction of inspired oxygen (Fio2) from the high-flow
REFERENCES
oxygen source near the sampling area (eg, flush flow
1. Tulchinsky A. An end-tidal goal of 90% O2 may be unattain-
oxygen source). This oxygen contamination then able during preoxygenation. Anesth Analg. 2021;133:e11–e12.
falsely elevates the Eto2 reading. Technically, to accu- 2. Kornas RL, Owyang CG, Sakles JC, Foley LJ, Mosier
rately measure Eto2, a “single breath”–forced expira- JM; Society for Airway Management’s Special Projects
tion after denitrogenation is required, as Driver et al3 Committee. Evaluation and management of the physiologi-
did in the flush rate preoxygenation study. This would cally difficult airway: consensus recommendations from soci-
ety for airway management. Anesth Analg. 2021;132:395–405.
provide a pure alveolar gas sample with no external 3. Driver BE, Klein LR, Carlson K, Harrington J, Reardon RF,
contamination. When measuring Eto2 continuously Prekker ME. Preoxygenation with flush rate oxygen: com-
with our current technology, it is difficult to get an paring the nonrebreather mask with the bag-valve mask.
accurate Eto2 reflective of alveolar gas rather than fresh Ann Emerg Med. 2018;71:381–386.
O2 inflow or dead space, which may be falsely elevated. DOI: 10.1213/ANE.0000000000005573
Therefore, when using Eto2 values as an indicator of
adequate denitrogenation, each exhalation should
result in a positive capnograph and the reservoir bag
should expand and contract with each respiratory Perioperative Lidocaine: Safety First!
Conflicts of Interest: J. C. Sakles has previously served as a consultant for To the Editor

W
Verathon Inc., Bothwell, WA. L. J. Foley is a paid consultant for Vyaire
Medical. J. M. Mosier is a paid consultant for Verathon, Inc. e read with interest the excellent open mind
R. L. Kornas and C. G. Owyang contributed equally. review of local anesthetic systemic toxic-
R. L. Kornas and C. G. Owyang are the co-first authors. ity (LAST). We agree with the author’s

e12   
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 E  Letters to the Editor
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Figure. Ensuring safety of IV lidocaine infusions: the use of IV PCA
Y-connector with an integral antisiphon (to prevent free-flow due to
gravity) and an antireflux valve (to prevent reflux into main IV line). IV
indicates intravenous; PCA, patient-controlled analgesia. Credit from
Eipe et al2; adapted from the original artwork by Perry Ng, Medical
Illustrator, Faculty of Medicine, uOttawa.
recommendation for caution with the perioperative use
of lidocaine.1 As early adopters of the opioid sparing
parenteral analgesic strategy, we introduced intrave-
nous (IV) lidocaine for acute pain as part of an enhanced
recovery after surgery (ERAS) protocol.2 In our own
center, it was the paradigm shift toward laparoscopic
colorectal surgery combined with the redundancy of
epidural analgesia and questionable risks of nonsteroi-
dal anti-inflammatory drugs (NSAIDs) in this surgical
model that prompted us to use IV lidocaine.3 Over the
past decade, we and others have further refined periop-
erative protocols and implemented continued training
and education of all providers.4 This has allowed for
the extension of the perioperative use of IV lidocaine
beyond colorectal surgery to spine, trauma, and vascu-
lar surgery with ongoing research elsewhere into ben-
efits of lidocaine in oncological surgical models.
We agree with the recommendation by Dr Weinberg1
for the need for continuous vigilance and meticulous
data collection for the safety of IV lidocaine. We would
like to add to that the safety of IV lidocaine has been
previously extensively studied over decades of exten-
sive use in cardiology as an antiarrhythmic. Here, it
was often used in greater doses, for longer periods,
and in patients, we would now consider to be at high
risk for adverse outcomes and LAST.5
To ensure patient safety, our own administration pro-
tocol, among others, has three important components:
the use of commercially available dilute IV lidocaine
July 2021 • Volume 133 • Number 1 www.anesthesia-analgesia.org e13
Copyright © 2021 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
solutions, dedicated programmed pumps, and special-
ized valves in the administration tubing (Figure). In our
experience, programming errors and inadvertent boluses
of IV lidocaine are most likely the causes of LAST. As
mentioned by Dr Weinberg,1 the latter was the case of
our only serious life-threatening toxicity in our institu-
tion.4 To protect against “gravity free flow” from the bag
of IV lidocaine, we use a special connector with an antisi-
phon valve on the short limb of the connector. This valve
requires a pressure from a pump to allow drug to pass
through the valve and reach the patient. The antireflux
valve on the long limb of the connector prevents the drug
from flowing retrograde up the main IV tubing should
the venous access get partially or completely occluded. If
these valves are present, the drug will not flow if the lido-
caine tubing is inadvertently removed from the pump
nor enter the other fluids being coadministered.6
We also concur with the debate by Dr Weinberg1
around the usefulness and efficacy of perioperative
lidocaine. While this continues to be studied with good
quality clinical trials, there has been lack of overall effi-
cacy being suggested by systematic reviews and meta-
analyses. We believe that this requires us to revisit the
possible mechanism of analgesic action and identify
those patients and procedures where the benefits of
lidocaine may outweigh possible risks of LAST. There
is well-established evidence and experience from the
use of IV lidocaine for chronic pain that confirms its
effectiveness for neuropathic pain.7 In our experience,
in the acute pain setting, the efficacy of antihyperal-
gesics is seen in patients and procedures associated
with pronociception. Further studies are required to 3
confirm this and the use of diagnostic tools such as the
DN4 (Douleur Neuropathique en 4) questionnaire to
identify patients who would benefit from IV lidocaine.
Overall, we welcome the words of caution, call for
vigilance, and the need for a data registry for the periop-
erative use of IV lidocaine by Dr Weinberg.1 Rather than
abandoning the use of IV lidocaine, we believe that there
should be efforts at further protocol standardization and
expert consensus to improve the safety and outcomes
from perioperative lidocaine use. In the meantime, as we
and others have suggested, some patients undergoing
certain procedures will benefit from the perioperative
use of IV lidocaine, and these patients and procedures
need to be identified and continually studied.
Naveen Eipe, MD
John Penning, MD, FRCPC
Department of Anesthesiology and Pain Medicine
University of Ottawa
Ottawa, Ontario, Canada
neipe@toh.ca
REFERENCES
1. Weinberg GL. Perioperative lidocaine infusion: does the
risk outweigh the benefit? Anesth Analg. 2021;132:906–909.
 Letters to the Editor

2. Eipe N, Gupta S, Penning J. Intravenous lidocaine for acute
pain—an evidence based clinical update. BJA Educ. 2016;
16:292–298.
3. Eipe N, Penning J. Bowel surgery and multimodal anal-
gesia: same game, new team? Anesth Analg. 2009;109:
1703–1704.
4. De Oliveira K, Eipe N. Intravenous lidocaine for acute pain:
a single-institution retrospective study. Drugs Real World
Outcomes. 2020;7:205–212.
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2. Eipe N, Penning J. Perioperative lidocaine, safety first!
Anesth Analg. 2021;133:e12–e14.
3. Martí-Carvajal AJ, Simancas-Racines D, Anand V,
Bangdiwala S. Prophylactic lidocaine for myocardial infarc-
tion. Cochrane Database Syst Rev. 2015:CD008553.
4. Tisdale JE. Lidocaine prophylaxis in acute myocardial
infarction. Henry Ford Hosp Med J. 1991;39:217–225.
5. Macfarlane AJR, Gitman M, Bornstein KJ, El-Boghdadly K,
Weinberg G. Updates in our understanding of local anaes-

5. Collinsworth KA, Kalman SM, Harrison DC. The clinical thetic systemic toxicity: a narrative review. Anaesthesia.
Ho4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/08/2023

pharmacology of lidocaine as an antiarrhythymic drug. 2021;76(suppl 1):27–39.

Circulation. 1974;50:1217–1230.
DOI: 10.1213/ANE.0000000000005582
6. Penning JP. From the journal archives: apparatus for
demand analgesia with parenteral opioids: from lead-
ing role to supporting cast. Can J Anaesth. 2014;61:1050–
1054.
Expanding on The Origins, Evolution,
7. Kandil E, Melikman E, Adinoff B. Lidocaine infusion: a and Spread of Anesthesia Monitoring
promising therapeutic approach for chronic pain. J Anesth
Clin Res. 2017;8:697. Standards
DOI: 10.1213/ANE.0000000000005581

To the Editor

W
e thank the authors of the article titled,
In Response

I
“The Origins, Evolution, and Spread of
thank Dr Eipe and Penning for their reply to
Anesthesia Monitoring Standards: From
“Perioperative Lidocaine Infusion: Does the Risk
Boston to Around the World,” for their excellent sum-
Outweigh the Benefit?”.1 Their supportive com-
mary of our work in developing the first standards
ments, embodied in the apt title of their letter to the
of care in the specialty of anesthesiology.1 We wish to
editor, “Perioperative Lidocaine, Safety First!,”2 are
clarify and expand on a few points.
much appreciated. I’m especially gratified to see the
In 1984, the chiefs of Harvard Medical School’s
thoughtful consideration that their team has made to
anesthesia departments asked us to “study” the prob-
improve the safety of lidocaine infusion. Their atten-
lem of disproportionately high payouts relative to
tion to practice parameters, education, and systems
anesthesia claims. Having concluded that continuous
improvement (viz, the Y-connector design) reflects a
monitoring was key to detecting preventable errors,
considered approach to improving patient safety. One
we mandated minimal monitoring standards that
potentially discordant note, I don’t believe lidocaine
would include what prudent anesthesiologists were
infusion as an antiarrhythmic supports its routine
already doing. We rejected “recommendations” and
perioperative use for analgesia. Prophylactic lido-
“guidelines.” If approved by the anesthesia depart-
caine for myocardial infarction fell from favor when a
ment chiefs, we would set the precedent that these
lack of survival benefit failed to justify the frequency
basic rules should be followed by all anesthesia pro-
of adverse events.3,4 Along these lines, I agree with the
viders at our hospitals. We could and did add other
authors’ point that establishing a means to appropri-
standards over the next few years.2
ate patient selection can mitigate the risk of local anes-
While the emphasis was on practice behaviors,
thetic toxicity.5 That is, weighing for each patient the
new technologies greatly exceeded the ability of
presumed benefit with their specific risks can support
human senses to detect changes in oxygenation and
a rational approach in choosing lidocaine infusion.
ventilation, providing earlier warning of adverse
Mathematical models might also improve the accu-
events. However, pulse oximetry was not included
racy and objectivity of the process. The letter by Eipe
in the initial standards because it was quite new to
and Penning2 is an excellent starting point for the nec-
the vast majority of anesthesia providers. There was
essary discussion around standardizing this practice.
no evidence that its use was efficacious or improved
Guy L. Weinberg, MD outcomes. Mandating the use of pulse oximetry at
Department of Anesthesiology the time would have risked objections from some
University of Illinois College of Medicine vocal, influential anesthesia faculty who might then
Jesse Brown Veterans Administration Medical Center have succeeded in blocking the entire effort.
Chicago, Illinois Even to this day, there are no well-controlled stud-
guyw@uic.edu ies showing a statistically significant benefit on out-
REFERENCES comes with pulse oximetry. While it is true that “not
1. Weinberg GL. Perioperative lidocaine infusion: does the everything that counts can be counted (and not every-
risk outweigh the benefit? Anesth Analg. 2021;132:906–909. thing that can be counted counts),” such an argument

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