title: A randomized trial of topical anesthesia comparing lidocaine versus lidocaine plus xylometazoline for unsedated transnasal upper gastrointestinal endoscopy.
abstract: BACKGROUND
  The optimal topical anesthesia regimen for unsedated transnasal endoscopy is unknown. The addition of a nasal decongestant, such as xylometazoline (X), to a topical anesthestic may improve patient comfort.
  
  
  OBJECTIVE
  To determine the effectiveness of lidocaine (L) versus L plus X (LX) for anesthesia in unsedated transnasal endoscopy.
  
  
  METHODS
  Consecutive participants of the Aklavik Helicobacter pylori project were prospectively randomly assigned to receive LX or L for unsedated transnasal 4.9 mm ultrathin endoscopy. The primary outcome was overall procedure discomfort on a validated 10-point visual analogue scale (1 = no discomfort, 10 = severe discomfort). Secondary outcomes included pain, endoscope insertion difficulty, gagging, adverse events and encounter times. Results were presented as mean +/- SD, difference in mean, 95% CI.
  
  
  RESULTS
  A total of 181 patients were randomly assigned to receive LX (n=94) and L (n=87). Baseline characteristics between the two groups were similar (mean age 40 years, 59% women). Overall, patient procedural discomfort with LX and L were 4.2+/-2.4 versus 3.9+/-2.1, respectively (0.29; 95% CI -0.39 to 0.96). Transnasal insertion difficulty was significantly lower with LX than with L (2.4+/-2.1 versus 3.2+/-2.8, respectively [-0.80; 95% CI -1.54 to -0.06]). Compared with L, the use of LX was associated with significantly less time needed to apply anesthesia (2.4+/-1.8 min versus 3.5+/-2.2 min, respectively [-1.10; 95% CI -1.71 min to -0.50 min]) and less time for insertion (3.2+/-1.8 min versus 3.9+/-2.2 min, respectively [-0.70 min; 95% CI -1.30 min to -0.10 min]). Epistaxis was rare but occurred less frequently with LX (1.1%) than with L (4.6%) (P=0.19).
  
  
  CONCLUSIONS
  LX did not improve patient comfort for transnasal endoscopy compared with L alone. However, LX was associated with less difficulty with endoscope transnasal insertion and reduced insertion time. Further studies on the optimal regimen and dosing of anesthesia are required.
authors.affiliation: Division of Gastroenterology, University of Alberta, Zeidler Ledcor Centre, Edmonton, Alberta. justin.cheung@ualberta.ca
authors.forename: Justin
authors.initials: J
authors.lastname: Cheung
authors.forename: Karen
authors.initials: K
authors.lastname: Goodman
authors.forename: Robert
authors.initials: R
authors.lastname: Bailey
authors.forename: Richard
authors.initials: R
authors.lastname: Fedorak
authors.forename: John
authors.initials: J
authors.lastname: Morse
authors.forename: Mario
authors.initials: M
authors.lastname: Millan
authors.forename: Tom
authors.initials: T
authors.lastname: Guzowski
authors.forename: Sander Veldhuyzen
authors.initials: SV
authors.lastname: van Zanten
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000772:Anesthesia, Local / Q000379:methods*; D000779:Anesthetics, Local / Q000008:administration & dosage*; D002648:Child; D004359:Drug Therapy, Combination; D016099:Endoscopy, Gastrointestinal / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D005756:Gastritis / Q000175:diagnosis; D016481:Helicobacter Infections / Q000175:diagnosis; D006801:Humans; D007093:Imidazoles / Q000008:administration & dosage*; D008012:Lidocaine / Q000008:administration & dosage*; D008297:Male; D008875:Middle Aged; D014663:Nasal Decongestants / Q000008:administration & dosage*; D009666:Nose; D059408:Pain Management; D010147:Pain Measurement; D012189:Retrospective Studies; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D000779:Anesthetics, Local; D007093:Imidazoles; D014663:Nasal Decongestants; D008012:Lidocaine; C009695:xylometazoline