Cocaine to prevent bleeding during nasotracheal intubation: A systematic review

Mo Haslund Larsen; Oscar Rosenkrantz; Mette Krag; Lars Simon Rasmussen; Dan Isbye

doi:10.1111/aas.70002

Cocaine to prevent bleeding during nasotracheal intubation: A systematic review

Mo Haslund Larsen, Oscar Rosenkrantz, Mette Krag, Lars Simon Rasmussen, Dan Isbye

Department of Clinical Medicine - Department of Clinical Epidemiology

Research output: Contribution to journal/Conference contribution in journal/Contribution to newspaper › Journal article › Research › peer-review

Abstract

BACKGROUND: Nasotracheal intubation is associated with a risk of epistaxis. Decongestion of the nasal mucosa reduces the risk of epistaxis, and different vasoconstrictors may be used. Cocaine has both decongestive and analgesic properties, but it also has side effects. In this systematic review, we aimed to evaluate if cocaine decreases the occurrence and severity of epistaxis when administered topically to the nasal mucosa before nasotracheal intubation.

METHODS: We conducted a systematic review and meta-analysis following the PRISMA guidelines based on a predefined protocol. We included randomized clinical trials comparing nasal cocaine to active comparators or placebo for nasotracheal intubation. Two reviewers independently screened studies for eligibility and performed data extraction. Relative risk with 95% confidence intervals was calculated. Predefined primary outcome measures were the occurrence and severity of epistaxis. Secondary outcomes were pain, mechanical complications, and patient-centered side effects. The risk of bias was evaluated using the revised Cochrane Risk of Bias 2 tool for randomized trials, and certainty of evidence on outcome level was assessed according to GRADE.

RESULTS: Six trials (n = 457) were included; one trial was judged as having a low risk of bias. All six trials provided information on the occurrence of epistaxis. The meta-analysis did not support a difference in the occurrence of epistaxis between cocaine and its comparators (fixed effect: relative risk 0.90 [95% confidence interval 0.75 to 1.09, I2 of 0%, certainty of evidence: low]). The severity of epistaxis was evaluated on incompatible scales and thus not suitable for meta-analysis. No studies reported on pain or mechanical complications associated with nasotracheal intubation, and data on patient-centered side effects were sparse.

CONCLUSION: This systematic review with meta-analysis demonstrated that the quantity and certainty of evidence on cocaine used for nasotracheal intubation is low and that there is no firm evidence for the benefits and harms of cocaine compared to other vasoconstrictors and topical analgetics or placebo. Consequently, sufficiently powered randomized trials assessing patient-centered outcomes, including outcomes on side effects, should be conducted before firm conclusions on cocaine for nasotracheal intubation can be drawn.

EDITORIAL COMMENT: Epistaxis can occur with nasotracheal intubation, and topical drug vasoconstrictor effects have been used to reduce this risk. This analysis shows that the evidence base supporting the use of cocaine for reducing the risk of epistaxis in nasotracheal intubation is uncertain.

Original language	English
Article number	e70002
Journal	Acta Anaesthesiologica Scandinavica
Volume	69
Issue	3
Pages (from-to)	e70002
ISSN	0001-5172
DOIs	https://doi.org/10.1111/aas.70002
Publication status	Published - Mar 2025

Keywords

Cocaine/adverse effects
Epistaxis/prevention & control
Hemorrhage/prevention & control
Humans
Intubation, Intratracheal/adverse effects
Randomized Controlled Trials as Topic
nasotracheal intubation
cocaine
epistaxis

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10.1111/aas.70002

Cite this

@article{0847dafe8ba24c1694b8c281603337cf,

title = "Cocaine to prevent bleeding during nasotracheal intubation: A systematic review",

abstract = "BACKGROUND: Nasotracheal intubation is associated with a risk of epistaxis. Decongestion of the nasal mucosa reduces the risk of epistaxis, and different vasoconstrictors may be used. Cocaine has both decongestive and analgesic properties, but it also has side effects. In this systematic review, we aimed to evaluate if cocaine decreases the occurrence and severity of epistaxis when administered topically to the nasal mucosa before nasotracheal intubation.METHODS: We conducted a systematic review and meta-analysis following the PRISMA guidelines based on a predefined protocol. We included randomized clinical trials comparing nasal cocaine to active comparators or placebo for nasotracheal intubation. Two reviewers independently screened studies for eligibility and performed data extraction. Relative risk with 95% confidence intervals was calculated. Predefined primary outcome measures were the occurrence and severity of epistaxis. Secondary outcomes were pain, mechanical complications, and patient-centered side effects. The risk of bias was evaluated using the revised Cochrane Risk of Bias 2 tool for randomized trials, and certainty of evidence on outcome level was assessed according to GRADE.RESULTS: Six trials (n = 457) were included; one trial was judged as having a low risk of bias. All six trials provided information on the occurrence of epistaxis. The meta-analysis did not support a difference in the occurrence of epistaxis between cocaine and its comparators (fixed effect: relative risk 0.90 [95% confidence interval 0.75 to 1.09, I2 of 0%, certainty of evidence: low]). The severity of epistaxis was evaluated on incompatible scales and thus not suitable for meta-analysis. No studies reported on pain or mechanical complications associated with nasotracheal intubation, and data on patient-centered side effects were sparse.CONCLUSION: This systematic review with meta-analysis demonstrated that the quantity and certainty of evidence on cocaine used for nasotracheal intubation is low and that there is no firm evidence for the benefits and harms of cocaine compared to other vasoconstrictors and topical analgetics or placebo. Consequently, sufficiently powered randomized trials assessing patient-centered outcomes, including outcomes on side effects, should be conducted before firm conclusions on cocaine for nasotracheal intubation can be drawn.EDITORIAL COMMENT: Epistaxis can occur with nasotracheal intubation, and topical drug vasoconstrictor effects have been used to reduce this risk. This analysis shows that the evidence base supporting the use of cocaine for reducing the risk of epistaxis in nasotracheal intubation is uncertain.",

keywords = "Cocaine/adverse effects, Epistaxis/prevention & control, Hemorrhage/prevention & control, Humans, Intubation, Intratracheal/adverse effects, Randomized Controlled Trials as Topic, nasotracheal intubation, cocaine, epistaxis",

author = "Larsen, {Mo Haslund} and Oscar Rosenkrantz and Mette Krag and Rasmussen, {Lars Simon} and Dan Isbye",

note = "{\textcopyright} 2025 The Author(s). Acta Anaesthesiologica Scandinavica published by John Wiley & Sons Ltd on behalf of Acta Anaesthesiologica Scandinavica Foundation.",

year = "2025",

month = mar,

doi = "10.1111/aas.70002",

language = "English",

volume = "69",

pages = "e70002",

journal = "Acta Anaesthesiologica Scandinavica",

issn = "0001-5172",

publisher = "Blackwell Munksgaard",

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Cocaine to prevent bleeding during nasotracheal intubation: A systematic review. / Larsen, Mo Haslund; Rosenkrantz, Oscar; Krag, Mette et al.
In: Acta Anaesthesiologica Scandinavica, Vol. 69, No. 3, e70002, 03.2025, p. e70002.

Research output: Contribution to journal/Conference contribution in journal/Contribution to newspaper › Journal article › Research › peer-review

TY - JOUR

T1 - Cocaine to prevent bleeding during nasotracheal intubation

T2 - A systematic review

AU - Larsen, Mo Haslund

AU - Rosenkrantz, Oscar

AU - Krag, Mette

AU - Rasmussen, Lars Simon

AU - Isbye, Dan

PY - 2025/3

Y1 - 2025/3

N2 - BACKGROUND: Nasotracheal intubation is associated with a risk of epistaxis. Decongestion of the nasal mucosa reduces the risk of epistaxis, and different vasoconstrictors may be used. Cocaine has both decongestive and analgesic properties, but it also has side effects. In this systematic review, we aimed to evaluate if cocaine decreases the occurrence and severity of epistaxis when administered topically to the nasal mucosa before nasotracheal intubation.METHODS: We conducted a systematic review and meta-analysis following the PRISMA guidelines based on a predefined protocol. We included randomized clinical trials comparing nasal cocaine to active comparators or placebo for nasotracheal intubation. Two reviewers independently screened studies for eligibility and performed data extraction. Relative risk with 95% confidence intervals was calculated. Predefined primary outcome measures were the occurrence and severity of epistaxis. Secondary outcomes were pain, mechanical complications, and patient-centered side effects. The risk of bias was evaluated using the revised Cochrane Risk of Bias 2 tool for randomized trials, and certainty of evidence on outcome level was assessed according to GRADE.RESULTS: Six trials (n = 457) were included; one trial was judged as having a low risk of bias. All six trials provided information on the occurrence of epistaxis. The meta-analysis did not support a difference in the occurrence of epistaxis between cocaine and its comparators (fixed effect: relative risk 0.90 [95% confidence interval 0.75 to 1.09, I2 of 0%, certainty of evidence: low]). The severity of epistaxis was evaluated on incompatible scales and thus not suitable for meta-analysis. No studies reported on pain or mechanical complications associated with nasotracheal intubation, and data on patient-centered side effects were sparse.CONCLUSION: This systematic review with meta-analysis demonstrated that the quantity and certainty of evidence on cocaine used for nasotracheal intubation is low and that there is no firm evidence for the benefits and harms of cocaine compared to other vasoconstrictors and topical analgetics or placebo. Consequently, sufficiently powered randomized trials assessing patient-centered outcomes, including outcomes on side effects, should be conducted before firm conclusions on cocaine for nasotracheal intubation can be drawn.EDITORIAL COMMENT: Epistaxis can occur with nasotracheal intubation, and topical drug vasoconstrictor effects have been used to reduce this risk. This analysis shows that the evidence base supporting the use of cocaine for reducing the risk of epistaxis in nasotracheal intubation is uncertain.

AB - BACKGROUND: Nasotracheal intubation is associated with a risk of epistaxis. Decongestion of the nasal mucosa reduces the risk of epistaxis, and different vasoconstrictors may be used. Cocaine has both decongestive and analgesic properties, but it also has side effects. In this systematic review, we aimed to evaluate if cocaine decreases the occurrence and severity of epistaxis when administered topically to the nasal mucosa before nasotracheal intubation.METHODS: We conducted a systematic review and meta-analysis following the PRISMA guidelines based on a predefined protocol. We included randomized clinical trials comparing nasal cocaine to active comparators or placebo for nasotracheal intubation. Two reviewers independently screened studies for eligibility and performed data extraction. Relative risk with 95% confidence intervals was calculated. Predefined primary outcome measures were the occurrence and severity of epistaxis. Secondary outcomes were pain, mechanical complications, and patient-centered side effects. The risk of bias was evaluated using the revised Cochrane Risk of Bias 2 tool for randomized trials, and certainty of evidence on outcome level was assessed according to GRADE.RESULTS: Six trials (n = 457) were included; one trial was judged as having a low risk of bias. All six trials provided information on the occurrence of epistaxis. The meta-analysis did not support a difference in the occurrence of epistaxis between cocaine and its comparators (fixed effect: relative risk 0.90 [95% confidence interval 0.75 to 1.09, I2 of 0%, certainty of evidence: low]). The severity of epistaxis was evaluated on incompatible scales and thus not suitable for meta-analysis. No studies reported on pain or mechanical complications associated with nasotracheal intubation, and data on patient-centered side effects were sparse.CONCLUSION: This systematic review with meta-analysis demonstrated that the quantity and certainty of evidence on cocaine used for nasotracheal intubation is low and that there is no firm evidence for the benefits and harms of cocaine compared to other vasoconstrictors and topical analgetics or placebo. Consequently, sufficiently powered randomized trials assessing patient-centered outcomes, including outcomes on side effects, should be conducted before firm conclusions on cocaine for nasotracheal intubation can be drawn.EDITORIAL COMMENT: Epistaxis can occur with nasotracheal intubation, and topical drug vasoconstrictor effects have been used to reduce this risk. This analysis shows that the evidence base supporting the use of cocaine for reducing the risk of epistaxis in nasotracheal intubation is uncertain.

KW - Cocaine/adverse effects

KW - Epistaxis/prevention & control

KW - Hemorrhage/prevention & control

KW - Humans

KW - Intubation, Intratracheal/adverse effects

KW - Randomized Controlled Trials as Topic

KW - nasotracheal intubation

KW - cocaine

KW - epistaxis

UR - http://www.scopus.com/inward/record.url?scp=85218941867&partnerID=8YFLogxK

U2 - 10.1111/aas.70002

DO - 10.1111/aas.70002

M3 - Journal article

C2 - 39956953

SN - 0001-5172

VL - 69

SP - e70002

JO - Acta Anaesthesiologica Scandinavica

JF - Acta Anaesthesiologica Scandinavica

IS - 3

M1 - e70002

ER -

Cocaine to prevent bleeding during nasotracheal intubation: A systematic review

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