Effect of intratracheal dexmedetomidine combined with ropivacaine on postoperative sore throat: a prospective randomised double-blinded controlled trial

Postoperative Sore Throat After Tracheal Intubation: An Updated Narrative Review and Call for Action

Background

Postoperative sore throat (POST) represents a common airway complication closely related to endotracheal tube (ETT), exhibiting a higher incidence following tracheal intubation compared to other airway apparatuses. Nevertheless, considering its mild and self-limiting character, POST is often overlooked. This study provides an updated narrative review on the latest perspectives regarding POST, including a comprehensive summary of its mechanisms, risk factors, clinical assessment methods, prevention and treatment strategies. Additionally, directions for future research are proposed.

Methods

A comprehensive search was conducted using keywords such as "postoperative sore throat" and "tracheal intubation" in PubMed, Web of Science, and Cochrane databases from their inception to October 2024. Two groups of reviewers independently performed data search and cleaning after standard training. To address gaps in knowledge or potential biases, the literature was thoroughly screened based on established criteria, and a comprehensive synthesis, analysis, and summary of the relevant findings was conducted.

Results

The precise cause of POST remains unknown, and its potential mechanism is believed to involve secondary inflammation triggered by irritation, mechanical trauma, tracheal intubation, and cuff inflation. The risk factors for POST encompass preoperative, intraoperative, and postoperative factors. Currently, effective prevention methods for POST consist of pharmacological interventions, non-pharmacological interventions, and traditional Chinese medicine (TCM) therapy. In terms of pharmacological interventions, non-steroidal anti-inflammatory drugs (NSAIDs) and steroid can effectively prevent the occurrence of POST through their anti-inflammatory properties. However, given the unavoidable side effects of medications, non-pharmacological interventions and non-invasive methods may offer greater benefits for POST and related hoarseness. For example, proficient and gentle intubation techniques can prevent mechanical injury caused by repeated intubation attempts. Currently, several studies have demonstrated the potential role of TCM in managing POST. Nonetheless, the precise mechanisms underlying its effects remain to be elucidated, and the available clinical evidence is still limited.

Conclusion

Given that POST is prevalent following tracheal intubation but frequently overlooked, we advocate heightened awareness of its occurrence and progression, and recommend integrating the prevention and management of POST into routine clinical practice.

Comparison of Preoperative Topical Magnesium Sulfate Spraying and Magnesium Sulfate Gargling for the Prevention of Postoperative Sore Throat after Tracheal Intubation: A Randomized, Double-Blind, Non-Inferiority Trial

Background and Aim

Postoperative sore throat is a common complication following endotracheal intubation, which can significantly affect patient comfort and recovery. The purpose of this study is that compares the efficacy of preoperative topical magnesium sulfate spraying with that of magnesium sulfate gargling aimed at preventing postoperative sore throat.

Patients and Methods

236 Participants were randomly allocated to either the magnesium sulfate spray group (Group A) or the magnesium sulfate gargle group (Group B), with 118 patients in each group. In Group A, during intubation under direct laryngoscopy, 15 mg/kg of magnesium sulfate was sprayed using a single-use otorhinolaryngology anesthesia sprayer onto the pharyngeal mucosa and posterior pharyngeal wall near the glottis. In Group B, gargling with 20 mg/kg of magnesium sulfate for 30 seconds 15 minutes before surgery. The primary outcome measure was the total incidence of postoperative sore throat within 48 hours, with a non-inferiority margin of 0.15.

Results

The upper limit of the 95% confidence interval (CI) for the difference in the total incidence of POST between Group A and Group B was below the non-inferiority margin (0.15) (non-inferiority P<0.001). The upper limits of the 95% CI for the differences in the incidence rates of POST between Group A and Group B at time points T1- T6 were all below the non-inferiority margin (all non-inferiority P<0.001). The total incidence of POST (P=0.046) and the incidence of POST at T2-T4 (all P<0.001) in group A were lower than those in group B. The analysis of the individual effects between groups indicated significant differences in POST NRS scores at T1 (P=0.034) and T2-T4 (all P<0.001).

Conclusion

The local spray of magnesium sulfate on the throat before surgery to prevent postoperative sore throat is not inferior to, and may even be superior to, gargling with magnesium sulfate.

Effects of preoperative inhaled budesonide combined with intravenous dexamethasone on postoperative sore throat in patients who underwent thyroidectomy: A randomized controlled trial

BACKGROUND

This randomized controlled trial aimed to evaluate the efficacy of preoperative inhaled budesonide combined with intravenous dexamethasone on postoperative sore throat (POST) after general anesthesia in patients who underwent thyroidectomy.

METHODS

Patients who underwent elective thyroidectomy were randomly divided into the intravenous dexamethasone group (group A) and budesonide inhalation combined with intravenous dexamethasone group (group B). All patients underwent general anesthesia. The incidence and severity of POST, hoarseness, and cough at 1, 6, 12, and 24 hours after surgery were evaluated and compared between the 2 groups.

RESULTS

There were 48 and 49 patients in groups A and B, respectively. The incidence of POST was significantly lower at 6, 12, and 24 hours in group B than that in group A (P < .05). In addition, group B had a significantly lower incidence of coughing at 24 hours (P = .047). Compared with group A, the severity of POST was significantly lower at 6 (P = .027), 12 (P = .004), and 24 (P = .005) hours at rest, and at 6 (P = .002), 12 (P = .038), and 24 (P = .015) hours during swallowing in group B. The incidence and severity of hoarseness were comparable at each time-point between the 2 groups (P > .05).

CONCLUSION

Preoperative inhaled budesonide combined with intravenous dexamethasone reduced the incidence and severity of POST at 6, 12, and 24 hours after extubation compared with intravenous dexamethasone alone in patients who underwent thyroidectomy. Additionally, this combination decreased the incidence of postoperative coughing at 24 hours.

Leveraging artificial intelligence to identify high-risk patients for postoperative sore throat: An observational study

Postoperative sore throat (POST) is a prevalent complication after general anesthesia and targeting high-risk patients helps in its prevention. This study developed and validated a machine learning model to predict POST. A total number of 834 patients who underwent general anesthesia with endotracheal intubation were included in this study. Data from a cohort of 685 patients was used for model development and validation, while a cohort of 149 patients served for external validation. The prediction performance of random forest (RF), neural network (NN), and extreme gradient boosting (XGBoost) models was compared using comprehensive performance metrics. The Local Interpretable Model-Agnostic Explanations (LIME) methods elucidated the best-performing model. POST incidences across training, validation, and testing cohorts were 41.7%, 38.4%, and 36.2%, respectively. Five predictors were age, sex, endotracheal tube cuff pressure, endotracheal tube insertion depth, and the time interval between extubation and the first drinking of water after extubation. After incorporating these variables, the NN model demonstrated superior generalization capabilities in predicting POST when compared to the XGBoost and RF models in external validation, achieving an area under the receiver operating characteristic curve (AUROC) of 0.81 (95% CI 0.74-0.89) and a precision-recall curve (AUPRC) of 0.77 (95% CI 0.66-0.86). The model also showed good calibration and clinical usage values. The NN model outperforms the XGBoost and RF models in predicting POST, with potential applications in the healthcare industry for reducing the incidence of this common postoperative complication.

Comparison of nebulized ropivacaine (0.75%) with nebulized dexmedetomidine on the hemodynamic response on intubation in patients undergoing surgery under general anesthesia: A comparative randomized double-blind placebo-controlled study

Background

Laryngoscopy and tracheal intubation lead to sympathetic stimulation resulting in hemodynamic fluctuations. We compared local anesthetic ropivacaine 0.75% with alpha agonist dexmedetomidine through ultrasonic nebulization for direct local action of the drug in the airway.

Methods

In our randomized study, 180 patients were prospectively assigned to three groups of 60 each: group R (0.75%), group D (1 microgram/kg), and group C (control). The primary objective was to determine whether nebulized ropivacaine or nebulized dexmedetomidine can cause a reduction in stress response to laryngoscopy and intubation. The secondary objectives were to compare the hemodynamic parameters at extubation, cough response at extubation, and postoperative sore throat.

Results

A total of 165 patients were analyzed. Demographically, all the groups were similar. Group R and group D were found to significantly attenuate the heart rate (HR) at intubation and extubation when compared to group C (P < 0.05). A significant reduction in mean arterial pressure (MAP) was seen (P < 0.05; group D: 90 ± 18.4 mmHg, group C: 99.5 ± 15.9 mmHg, group R: 92.4 ± 16.1 mmHg). There was a significant reduction in cough response in both groups in comparison with group C at 0 minutes (P value; group C vs group D: <.0001; group C vs group R:.01) and 5 minutes (P value; group C vs group D: <.0001; group C vs group R: <.0001).

Conclusion

Preinduction topical use of ropivacaine or dexmedetomidine, through the nebulization route, effectively attenuated the pressor responses when compared to placebo.

Effect of Different Administration Routes of Dexmedetomidine on Postoperative Delirium in Elderly Patients Undergoing Elective Spinal Surgery: A Prospective Randomized Double-Blinded Controlled Trial

BACKGROUND

Intravenous dexmedetomidine has been reported to decrease the occurrence of postoperative delirium (POD) in elderly patients. Nevertheless, some previous studies have indicated that intratracheal dexmedetomidine and intranasal dexmedetomidine are also effective and convenient. The current study aimed to compare the effect of different administration routes of dexmedetomidine on POD in elderly patients.

METHODS

We randomly allocated 150 patients (aged 60 years or more) scheduled for spinal surgery to receive intravenous dexmedetomidine (0.6 μg/kg), intranasal dexmedetomidine (1 μg/kg) before anesthesia induction, or intratracheal dexmedetomidine (0.6 µg/kg) after anesthesia induction. The primary outcome was the frequency of delirium during the first 3 postoperative days. The secondary outcomes were the incidence of postoperative sore throat (POST) and sleep quality. Adverse events were recorded, and routine treatment was performed.

RESULTS

Compared with the intranasal group, the intravenous group had a significantly lower occurrence of POD within 3 days (3 of 49 [6.1%] vs 14 of 50 [28.0%]; odds ratio [OR], 0.17; 95% confidence intervals [CIs], 0.05-0.63; P < .017). Meanwhile, patients in the intratracheal group had a lower incidence of POD than those in the intranasal group (5 of 49 [10.2%] vs 14 of 50 [28.0%]; OR, 0.29; 95% CI, 0.10-0.89; P < .017). Whereas, there was no difference between the intratracheal and intravenous groups (5 of 49 [10.2%] vs 3 of 49 [6.1%]; OR, 1.74; 95% CI, 0.40-7.73; P > .017). The rate of POST was lower in the intratracheal group than that in the other 2 groups at 2 hours after surgery (7 of 49 [14.3%] vs 12 of 49 [24.5%] vs 18 of 50 [36.0%], P < .017, respectively). Intravenous dexmedetomidine had the lowest Pittsburgh Sleep Quality Index score on the second morning after surgery (median [interquartile range {IQR}]: 4 [3-5] vs 6 [4-7] vs 6 [4-7], P < .017, respectively). Compared with the intranasal group, the intravenous group had a higher rate of bradycardia and a lower incidence of postoperative nausea and vomiting ( P < .017). The intranasal group was associated with the highest incidence of hypertension ( P < .017).

CONCLUSIONS

For patients aged ≥60 years undergoing spinal surgery, compared with the intranasal route of dexmedetomidine, intravenous and intratracheal dexmedetomidine reduced the incidence of early POD. Meanwhile, intravenous dexmedetomidine was associated with better sleep quality after surgery, and intratracheal dexmedetomidine resulted in a lower incidence of POST. Adverse events were mild in all 3 administration routes of dexmedetomidine.

Can low dose of intratracheal dexmedetomidine be used to attenuate peri-extubation cough? - A prospective, double-blinded, randomized clinical trial

Background

Peri-extubation cough is an undesirable event during extubation, prevention of which has been studied with multiple drugs, amongst which intravenous dexmedetomidine has emerged as one of the favourable drugs. Intratracheal route is attractive because of its ease of administration, provided it avoids the hypotension and bradycardia that occurs during intravenous bolus administration. There is a paucity of data exploring the utility, doses, and adverse effect of intratracheal dexmedetomidine.

Methods

After obtaining ethical committee approval, 60 eligible, consenting adult patients undergoing surgery under general anesthesia in a tertiary teaching hospital were recruited and randomised into three groups-DEX0.3, DEX0.5, and NS. The plan of general anesthesia was standardized. Half an hour prior to extubation, study drug was instilled intratracheally-dexmedetomidine 0.3 mic/kg, 0.5 mic/kg, and NS in groups DEX0.3, DEX0.5, and NS, respectively. 4-point cough score was used to assess extubation response. Hemodynamic response and time to Ramsay sedation score 3 was also recorded.

Results

Majority of patients in DEX0.3 (60%) and DEX0.5 (85%) group had no cough (cough score 0), while majority of the patients in the NS group (70%) had either mild or moderate cough (cough score 1, 2). Kruskal Wallis test followed by post-hoc pairwise comparison showed statistically significant difference in 4-point cough score between GroupDEX0.3 and GroupNS (P < 0.001) and between GroupDEX0.5 and GroupNS (P = 0.038). DEX0.5 group, compared to DEX0.3 group, had significantly higher time from reversal to extubation (P < 0.001) and time to achieve Ramsay sedation score of 3 (P < 0.001).

Conclusion

We conclude that both 0.3 mic/kg and 0.5 mic/kg of dexmedetomidine when given intratracheally are effective in preventing peri-extubation cough. Further, 0.3 mic/kg dexmedetomidine showed a better recovery profile compared to 0.5 mic/kg dexmedetomidine when administered intratracheally.