There are many ways to adequately topicalise an airway, which depend on personal and institutional experience, and the available drugs in different parts of the world.   This is a step-by-step set of instructions on how to make the “GSH Mix” in use at Groote Schuur Hospital, Cape Town, South Africa.  Note that we don’t have access to certain ingredients which are commonly available elsewhere (such as viscous lignocaine or Moffett’s solution).

End product:  4 % (or 5%) lignocaine with 20 mcg/ml adrenaline.

You’ll need:

• Three 10 ml syringes
• Needles to draw up drugs
• Syringe labels and marker pen
• 5 ml 10% lignocaine (‘Remicard 10% in SA)
• 1 mg/1 ml adrenaline (1:1000)
• Two 10 ml normal saline ampoules to dilute
• Nebuliser mask

Label the syringes clearly:  100 mcg/ml adrenaline (1:10 000) and 4 % lignocaine with 20 mcg/ml adrenaline:

Draw the adrenaline (1 mg/1 ml) into the adrenaline syringe, and dilute with saline to 10 ml (100 mcg/ml, or 1:10 000 solution):
Transfer 2 ml (200 mcg) of the dilute adrenaline into the mix syringe: Add 4 ml of the 10 % lignocaine solution to the mix syringe (use all 5 ml if you want to make a 5 % solution rather than the usual 4 %): Add saline to the mix syringe to a total volume of 10 ml.  You now have 4 % (or 5 %) lignocaine with 20 mcg/ml adrenaline: Put 5 ml of the mix into the nebuliser mask, ready to commence topicalisation by neb: Split the remaining 5 ml mixture into two 10 ml syringes (using your third syringe) to be used for spray-as-you-go through the scope if needed:
Put the rest of the adrenaline solution somewhere safe (or discard it), and draw back the plungers on the mix syringes all the way.  This introduces air which then blows the local mix through the scope when you do spray-as-you-go.  Don’t forget to give the neb plenty of time to work (15-20 minutes, until complete). Don’t forget to use adjuvant strategies to improve your topicalisation, such as gargling, atomised spray, or topical gel/paste, and enter your cases into a registry such as TheAirwayApp so that we can build worldwide experience with different techniques!