The effects of lidocaine spray and intracuff alkalinized lidocaine on the occurrence of cough at extubation: a double-blind randomized controlled trial

Intracuff Lidocaine and Postoperative Throat Mucosal Injuries: An Evidence-based Review

PURPOSE

Examine the effectiveness of using intracuff lidocaine to minimize postoperative complications.

DESIGN

Systematic review.

METHODS

This review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Guidelines. PubMed, CINAHL, Cochrane, Google Scholar, and gray literature databases were searched to obtain eligible studies and minimize selection bias. The Johns Hopkins Nursing Evidence-Based Practice Model was used to appraise the level of evidence for the varying studies. Only randomized controlled trials (RCT) and systematic reviews with meta-analyses of RCTs were included in the review.

FINDINGS

Three RCTs and three systematic reviews with meta-analyses incorporating a total of 2,337 patients were included in this review. Intracuff lidocaine (alkalinized and nonalkalinized) had the lowest incidence of postoperative sore throat in the early and late postoperative periods compared to intracuff air or intracuff saline. Furthermore, the evidence suggested that the use of intracuff lidocaine reduced postextubation cough and the incidence of hoarseness but had little or no effect on dysphagia. All studies were Level 1 and Grade A, indicating clinically solid evidence in analyzing intracuff lidocaine's effect on all outcomes measured.

CONCLUSIONS

The current literature suggests the feasibility of using intracuff lidocaine as an effective method to reduce the incidence of postoperative sore throat, postextubation cough, and hoarseness. The implications to practice include improving the norm of postoperative throat mucosal injuries by implementing an evidence-based practice intervention of intracuff lidocaine.

Multimodal prevention of emergence cough following nasal endoscopic surgery under general anesthesia: a double-blind randomized trial

Purpose

Cough during emergence from anesthesia is a common problem and may cause adverse events. Monotherapy faces uncertainty in preventing emergence cough due to individual differences. We aimed to evaluate the efficacy and safety of multimodal intervention for preventing emergence cough in patients following nasal endoscopic surgery.

Methods

In this double-blind randomized trial, 150 adult patients undergoing nasal endoscopic surgery were randomly allocated into three groups. For the control group (n = 50), anesthesia was performed according to clinical routine, no intervention was provided. For the double intervention group (n = 50), normal saline 3 mL was sprayed endotracheally before intubation, 0.4 μg/kg dexmedetomidine was infused over 10 min after intubation, and target-controlled remifentanil infusion was maintained at an effect-site concentration of 1.5 ng/mL before extubation after surgery. For the multimodal intervention group (n = 50), 0.5% ropivacaine 3 mL was sprayed endotracheally before intubation, dexmedetomidine and remifentanil were administered as those in the double intervention group. The primary endpoint was the incidence of emergence cough, defined as single cough or more from end of surgery to 5 min after extubation.

Results

The incidences of emergence cough were 98% (49/50) in the control group, 90% (45/50) in the double group, and 70% (35/50) in the multimodal group, respectively. The incidence was significantly lower in the multimodal group than those in the control (relative risk 0.71; 95% CI 0.59 to 0.86; p < 0.001) and double (relative risk 0.78; 95% CI 0.63 to 0.95; p = 0.012) groups; the difference between the double and control groups was not statistically significant (relative risk 0.92; 95% CI 0.83 to 1.02; p = 0.20). The severity of sore throat was significantly lower in the multimodal group than that in the control group (median difference-1; 95% CI -2 to 0; p = 0.016). Adverse events did not differ among the three groups.

Conclusion

For adult patients undergoing endonasal surgery, multimodal intervention including ropivacaine topical anesthesia before intubation, dexmedetomidine administration after intubation, and remifentanil infusion before extubation after surgery significantly reduced emergence cough and was safe.

Lidocaine aerosol preoperative application for improving the comfort of pediatric patients undergoing tonsillectomy and adenoidectomy: A prospective randomized controlled trial

Background and Aims

The use of lidocaine aerosol for pediatric tonsil and adenoidectomy has been reported less frequently. We hope to improve the perioperative comfort of pediatric patients undergoing these procedures by applying lidocaine aerosol.

Methods

A total of 122 pediatric patients receiving tonsil and adenoidectomy were randomly divided into a lidocaine aerosol group (Group L) and a saline group (Group C), with 61 patients in each group; 2.4% alkaline lidocaine aerosol and saline were sprayed in the pharynx before induction. Our primary outcome were the incidence and rate ratio (RR) of postoperative pharyngeal complications (oropharyngeal dryness, dysphagia, hoarseness, and sore throat) and the pharyngeal comfort score, the latter of which was assessed by the occurrence of the above complications (yes = 0 point, none = 1 point). The secondary outcomes included preoperative and intraoperative blood pressure and heart rate, the incidence of choking during the induction period, the intraoperative opioid dosage, and the pain level and depth of sedation at 2, 6, and 24 h postoperatively. Statistical software used in this study included PASS15.0, SPSS 26.0, and GraphPad Prism 9.3.1, and statistical methods used included the t-test, the χ² test, the Mann-Whitney U test, and the repeated measures analysis of variance.

Results

The incidence and RR of postoperative pharyngeal complications such as oropharyngeal dryness (RR: 0.667, 95% confidence interval [CI]: 0.458-0.970, p = 0.03), dysphagia (RR: 0.333, 95% CI: 0.114-0.976, p = 0.03), hoarseness (RR: 0.647, 95% CI: 0.433-0.967, p = 0.03), and sore throat (RR: 0.727, 95% CI: 0.547-0.967, p = 0.03) were significantly lower in Group L than in Group C at 2 h postoperatively, and the incidence and RR of postoperative sore throat was significantly lower in Group L than in Group C at 6 h postoperatively (RR: 0.717, 95% CI: 0.547-0.942, p = 0.01). The postoperative pharyngeal comfort scores were significantly higher in Group L than in Group C at all postoperative time points (p < 0.05). The Ramsay sedation score was significantly higher (p < 0.01) and FLACC (face, legs, activity, crying, and consolability) score was significantly lower (p < 0.01) in Group L than in Group C at 2 h postoperatively. In Group C, the blood pressure and heart rate significantly faster at all time points immediately after intubation and afterward, except at the end of surgery (p < 0.05).

Conclusions

In pediatric tonsil and adenoidectomy, the application of lidocaine aerosol before induction can reduce the incidence of postoperative pharyngeal complications, improve the child's postoperative pharyngeal comfort, and better realize perioperative "comfort medical treatment."

The Effect of Endotracheal Tube Cuff Shape on Post-extubation Sore Throat in Critically Ill Patients in a Rural Tertiary Care Hospital

BACKGROUND

Patients admitted to the critical care unit often require extended periods of mechanical ventilation. After extubation, patients often report discomfort in their throats, coughing, and hoarseness of voice. These symptoms have been linked to the shape of the cuff on the endotracheal tube and are described in terms of the surface area of the cuff in contact with the trachea.

METHODS

During this pilot study, 160 adults receiving intensive primary care were randomly assigned to one of two groups (Gathering A or Gathering B; 80 patients each). Intubated patients were separated into two groups: Group C consisted of those who wore a looser, barrel-shaped sleeve, and Group T consisted of those who wore a more restrictive sleeve. The severity of post-extubation side effects was assessed, including sore throat, dry voice, and hack, and the occurrence of these symptoms was also documented.

RESULT

Neither the number of intubation attempts nor the experience level of the residents who performed them differed significantly between the two groups (p > 0.05). A smaller percentage of patients in Gathering T experienced sore throats in the first, 12th, and 24th hours after extubation compared to patients in Group C at these same time points (p = 0.05). With time passing, fewer people in Group C and Group T experienced hoarseness of voice after extubation. There is a declining trend in the incidence of cough post-extubation in Group T, as compared to an initial increase in the trend for cough post-extubation with a gradual decline as time progressed in Group C.

CONCLUSION

There is an overall decrease in the incidence of post-extubation emergence phenomena with tapered shape cuffed endotracheal tubes when compared with conventional cylindrical type cuffed endotracheal tubes.

Intracuff alkalinized lidocaine to prevent postoperative airway complications: A meta-analysis

BACKGROUND

Post-extubation cough is a common phenomenon in surgical patients undergoing general anesthesia, which can lead to potentially dangerous complications. In this meta-analysis, we evaluated the efficacy and safety of intracuff alkalinized lidocaine in patients with tracheal intubation to prevent cough and other airway complications during the perioperative period.

AIM

To perform a systematic review and meta-analysis of intracuff alkalinized lidocaine for the prevention of postoperative airway complications.

METHODS

PubMed, Embase, Cochrane, and Web of Science were searched for randomized controlled trials (RCTs) that compared intracuff alkalinized lidocaine to placebo. We used risk-of-bias assessment to assess the RCTs, and the quality of evidence was assessed using the grading of recommendations, assessment, development, and evaluations.

RESULTS

Twelve randomized trials (1175 patients) were analyzed. Meta-analysis showed that intracuff alkalinized lidocaine was associated with less cough compared to that produced by placebo [risk ratio (RR): 0.38; 95% confidence interval (CI): 0.23-0.63]. Similarly, intracuff alkalinized lidocaine was more effective than the control in reducing postoperative sore throat at 24 h (RR: 0.19; 95%CI: 0.09-0.41) and postoperative hoarseness (RR: 0.38; 95%CI: 0.21-0.69).

CONCLUSION

Intracuff alkalinized lidocaine is an effective adjuvant that can decrease airway complications, such as coughing, hoarseness, and sore throat.

Impact of topical airway anesthesia on immediate postoperative cough/bucking: a systematic review and meta-analysis

BACKGROUND

Postoperative cough may occur after tracheal intubation, but it is indistinct which drug is best at diminishing these events. Additionally, airway reflexes are commonly accompanied by severe hemodynamics responses during emergence.

OBJECTIVES

To evaluate the role of topical airway anesthesia on immediate post-extubation cough/bucking and extubation time.

METHODS

Randomized clinical trials from MEDLINE, EMBASE, CENTRAL, and LILACS published until December 23, 2020 were included. Our primary outcome was postoperative cough/bucking incidence which was compared between local anesthetics and controls. Extubation times were likewise considered. Predisposition appraisal and subgroup, affectability investigations were likewise performed.

RESULTS

The pooled analysis found a 45% reduction in cough incidence after treatment with topical airway local anesthetic (RR.á=.á0.55; 95% CI: 0.42 to 0.72; p.á<.á0.001). The number needed to treat (NNT) was 4.61. The intervention showed no differences in reduction of the extubation time (mean difference = -0.07; 95% CI: -0.14 to 0.28; p.á=.á0.49).

CONCLUSION

Topical airway anesthesia demonstrated better than placebo or no medication in reducing immediate post-extubation cough/bucking. Further studies could have this objective to combine the different ways to perform better outcomes for patients.

Efficacy of intracuff lidocaine in reducing coughing on tube: a systematic review and meta-analysis

Objective

Method

Results

Conclusion

Trans-Cricothyroid Membrane Injection of Local Anesthesia Attenuates Cough Response and Postoperative Sore Throat to the Nasotracheal Tube

Objective

This study aims to investigate the effects of trans-cricothyroid membrane injection of local anesthesia on cough response and postoperative sore throat to the nasotracheal tube.

Methods

Patients who require general anesthesia with nasotracheal tube for oral and maxillofacial surgery were randomised divided into groups L and C. The patients in group L received trans-cricothyroid membrane injection of 2% lidocaine (3 mL) before anesthesia. Meanwhile, the same volume of 0.9% saline was administered to group C. The incidences of cough response, mean arterial pressure (MAP) and heart rate (HR) were recorded during emergency from general anesthesia. Postoperative sore throat (POST) was assessed at 1, 6, 12 and 24 h after surgery.

Results

The data of 60 patients in group L and 61 in group C were included in this study. The incidence of cough was lower in group L than in group C, ie, 41.7% vs 67.2% upon extubation (P=0.006) and 20.0% vs 41.0% at five minutes after extubation (P=0.018). MAP and HR in group L were significantly lower than in group C during emergency from general anesthesia (P<0.05). POST incidence was significantly reduced in group L at 1 and 6 h after surgery, ie, 35.0% vs 55.7% at 1 h after surgery (P=0.029) and 20.0% vs 37.7% at 6 h after surgery (P=0.044).

Conclusion

Trans-cricothyroid membrane injection of local anesthesia is a simple and effective method to attenuate the incidence of cough response during emergency from general anesthesia. This technique can reduce the incidence of POST after surgery.

Effects of dexmedetomidine vs sufentanil during percutaneous tracheostomy for traumatic brain injury patients: A prospective randomized controlled trial

BACKGROUND

Percutaneous tracheostomy, almost associated with cough reflex and hemodynamic fluctuations, is a common procedure for traumatic brain injury (TBI) patients, especially those in neurosurgery intensive care units (NICUs). However, there are currently a lack of effective preventive measures to reduce the risk of secondary brain injury. The aim of this study was to compare the effect of dexmedetomidine (DEX) vs sufentanil during percutaneous tracheostomy in TBI patients.

METHODS

The 196 TBI patients who underwent percutaneous tracheostomy were randomized divided into 3 groups: group D1 (n = 62, DEX infusion at 0.5 μg·kg for 10 minutes, then adjusted to 0.2-0.7 μg·kg·hour), group D2 (n = 68, DEX infusion at 1 μg·kg for 10 minutes, then adjusted to 0.2-0.7 μg·kg·hour), and group S (n = 66, sufentanil infusion 0.3 μg·kg for 10 minutes, then adjusted to 0.2-0.4 μg·kg·hour). The bispectral index (BIS) of all patients was maintained at 50 to 70 during surgery. Anesthesia onset time, hemodynamic variables, total cumulative dose of DEX/sufentanil, total doses of rescue propofol and fentanyl, time to first dose of rescue propofol and fentanyl, number of intraoperative patient movements and cough reflexes, adverse events, and surgeon satisfaction score were recorded.

RESULTS

Anesthesia onset time was significantly lower in group D2 than in both other groups (14.35 ± 3.23 vs 12.42 ± 2.12 vs 13.88 ± 3.51 minutes in groups D1, D2, and S, respectively; P < .001). Both heart rate and mean arterial pressure during percutaneous tracheostomy were more stable in group D2. Total doses of rescue propofol and fentanyl were significantly lower in group D2 than in group D1 (P < .001). The time to first dose of rescue propofol and fentanyl were significantly longer in group D2 than in both other groups (P < .001). The number of patient movements and cough reflexes during percutaneous tracheostomy were lower in group D2 than in both other groups (P < .001). The overall incidences of tachycardia and hypertension (which required higher doses of esmolol and urapidil, respectively) were also lower in group D2 than in both other groups (P < .05). Three patients in group S had respiratory depression compared to X in the D1 group and X in the D2 group. The surgeon satisfaction score was significantly higher in group D2 than in both other groups (P < .05).

CONCLUSIONS

During percutaneous tracheostomy, compared with sufentanil, DEX (1 μg·kg for 10 minutes, then adjusted to 0.2-0.7 μg·kg·hour) can provide the desired attenuation of the hemodynamic response without increased adverse events. Consequently, DEX could be used safely and effectively during percutaneous tracheostomy in TBI patients.

The Evaluation of Upper Airway Complications Secondary to Intubation: Cuff Pressure Manometer Versus Conventional Palpation Method

Objectives

General anesthesia is preferred in most otorhinolaryngologic surgeries. The aim of the present study was to evaluate upper airway complications secondary to intubation including sore throat, cough, dysphonia, and dysphagia considering endotracheal tube (ET) cuff pressure, tube diameter, and duration of intubation.

Methods

After the assignment of 67 patients to the study and control groups, ET cuff pressure was adjusted to be between 20 and 30 cm H₂O using a cuff pressure manometer in the study group. In the control group, the cuff pressure was decided by the anesthesiologist using the conventional palpation method. Sore throat, cough, dysphonia, and dysphagia were compared between the groups at 4, 8, and 24 h postoperatively.

Results

Cuff pressure was significantly higher in the control group than in the study group. In the control group, sore throat was more frequently observed at 4, 8, and 24 h, whereas in the study group, cough and dysphonia were more often observed at 4 and 8 h. At 4 and 8 h, cough was found to be related to the duration of intubation.

Conclusion

Arrangement of cuff pressure using a cuff manometer is suggested to decrease complications of the upper airway secondary to intubation because of the higher rate of these complaints in patients whose cuff pressure is arranged by the conventional palpation method.

Effect of transcutaneous electrical acupoint stimulation on the EC50 of remifentanil suppressing responses to tracheal extubation in elderly patients

Transcutaneous electrical acupoint stimulation (TEAS) is a emerging treatment which combines transcutaneous electrical nerve stimulation with traditional acupoint therapy. The present study was aimed to evaluate the effect of TEAS on the effective concentration (EC50) of remifentanil suppressing tracheal extubation response in elderly patients.Fifty-three patients undergoing spine surgery were randomly divided into 2 groups: control group (group C, n = 26) and transcutaneous electrical acupoint stimulation group (group TEAS, n = 27). The EC50 values for remifentanil TCI were determined using sequential method and probit analysis.The remifentanil EC50 of that suppressed responses to extubation during anesthetic emergence was 1.20 ng/mL in group TEAS, a value that was significantly lower than the 1.64 ng/mL needed by patients in group C.The TEAS can enhance the efficacy of remifentanil on suppressing responses to tracheal extubation in elderly patients, the EC50 of remifentanil can reduce approximately 27% compared with group C.

Tracheal cuff pressure change before and after the performance of nursing care

OBJECTIVE

Verify the changes of endotracheal cuff pressure before and after oral hygiene, head-of-bed elevation at 0º, 30º, and 60º, change in body position, aspiration of the endotracheal tube, and in-bed bathing.

METHOD

The study sample was composed of 88 patients. We performed 3,696 checks from July to September 2014.

RESULTS

Pressure values were analyzed in seven nursing care in the morning. Six of them were significantly altered before and after nursing procedure. In the afternoon, five of the health care provided were altered, and in the evening, only two. Most of pressure values were below recommended.

CONCLUSION

There were differences before and after health care provided, showing changes in cuff pressure. In-bed bathing and head-of-bed elevation at 30º were the ones that most altered pressure values in the three working shifts. Therefore, it is necessary to measure cuff pressure at least twice per working shift, preferably after bathing.

Local anesthetics for brain tumor resection: current perspectives

This review summarizes the added value of local anesthetics in patients undergoing craniotomy for brain tumor resection, which is a procedure that is carried out frequently in neurosurgical practice. The procedure can be carried out under general anesthesia, sedation with local anesthesia or under local anesthesia only. Literature shows a large variation in the postoperative pain intensity ranging from no postoperative analgesia requirement in two-thirds of the patients up to a rate of 96% of the patients suffering from severe postoperative pain. The only identified causative factor predicting higher postoperative pain scores is infratentorial surgery. Postoperative analgesia can be achieved with multimodal pain management where local anesthesia is associated with lower postoperative pain intensity, reduction in opioid requirement and prevention of development of chronic pain. In awake craniotomy patients, sufficient local anesthesia is a cornerstone of the procedure. An awake craniotomy and brain tumor resection can be carried out completely under local anesthesia only. However, the use of sedative drugs is common to improve patient comfort during craniotomy and closure. Local anesthesia for craniotomy can be performed by directly blocking the six different nerves that provide the sensory innervation of the scalp, or by local infiltration of the surgical site and the placement of the pins of the Mayfield clamp. Direct nerve block has potential complications and pitfalls and is technically more challenging, but mostly requires lower total doses of the local anesthetics than the doses required in surgical-site infiltration. Due to a lack of comparative studies, there is no evidence showing superiority of one technique versus the other. Besides the use of other local anesthetics for analgesia, intravenous lidocaine administration has proven to be a safe and effective method in the prevention of coughing during emergence from general anesthesia and extubation, which is especially appreciated after brain tumor resection.

Airway Complications during and after General Anesthesia: A Comparison, Systematic Review and Meta-Analysis of Using Flexible Laryngeal Mask Airways and Endotracheal Tubes

OBJECTIVE

Flexible laryngeal mask airways (FLMAs) have been widely used in thyroidectomy as well as cleft palate, nasal, upper chest, head and neck oncoplastic surgeries. This systematic review aims to compare the incidence of airway complications that occur during and after general anesthesia when using the FLMA and endotracheal intubation (ETT). We performed a quantitative meta-analysis of the results of randomized trials.

METHODS

A comprehensive search of the PubMed, Embase and Cochrane Library databases was conducted using the key words "flexible laryngeal mask airway" and "endotracheal intubation". Only prospective randomized controlled trials (RCTs) that compared the FLMA and ETT were included. The relative risks (RRs) and the corresponding 95% confidence intervals (95% CIs) were calculated using a quality effects model in MetaXL 1.3 software to analyze the outcome data.

RESULTS

Ten RCTs were included in this meta-analysis. There were no significant differences between the FLMA and ETT groups in the incidence of difficulty in positioning the airway [RR = 1.75, 95% CI = (0.70-4.40)]; the occurrence of sore throat at one hour and 24 hours postoperative [RR = 0.90, 95% CI = (0.13-6.18) and RR = 0.95, 95% CI = (0.81-1.13), respectively]; laryngospasms [RR = 0.58, 95% CI = (0.27-1.23)]; airway displacement [RR = 2.88, 95% CI = (0.58-14.33)]; aspiration [RR = 0.76, 95% CI = (0.06-8.88)]; or laryngotracheal soiling [RR = 0.34, 95% CI = (0.10-1.06)]. Patients treated with the FLMA had a lower incidence of hoarseness [RR = 0.31, 95% CI = (0.15-0.62)]; coughing [RR = 0.28, 95% CI = (0.15-0.51)] during recovery in the postanesthesia care unit (PACU); and oxygen desaturation [RR = 0.43, 95% CI = (0.26-0.72)] than did patients treated with ETT. However, the incidence of partial upper airway obstruction in FLMA patients was significantly greater than it was for ETT patients [RR = 4.01, 95% CI = (1.44-11.18)].

CONCLUSION

This systematic review showed that the FLMA has some advantages over ETT because it results in a lower incidence of hoarseness, coughing and oxygen desaturation. There were no statistically significant differences in the difficulty of intubation or in the occurrence of laryngospasms, postoperative sore throat, airway displacement, aspiration or laryngotracheal soiling. However, there was a higher incidence of partial upper airway obstruction in the FLMA than in the ETT group. We conclude that the FLMA has some advantages over ETT, but surgeons and anesthesiologists should be cautious when applying the mouth gag, moving the head and neck, or performing oropharyngeal procedures to avoid partial upper airway obstruction and airway displacement. The FLMA should not be used on patients at high risk for aspiration.

Lignocaine topicalization of the pediatric airway

The application of topical laryngeal lignocaine is a technique used frequently in pediatric anesthesia. It is often used to facilitate open airway procedures, tracheal intubation, or to reduce the incidence of perioperative adverse respiratory events such as coughing and laryngospasm. A number of studies have shown that applying topical lignocaine to the larynx reduces perioperative respiratory adverse events, while others have shown an increased incidence of respiratory complications with lignocaine administration. There is a lack of evidence on the effect of topical lignocaine on the sensitivity of upper airway reflexes and swallowing, the duration of time that airway reflexes are obtunded, and the optimum and safe maximum dose of lignocaine when used by this route. We review the current literature relating to the use of lignocaine to topicalize the pediatric airway. This review concentrates on the indications for use, the maximum safe dose, the effect on swallowing, and risk of aspiration and the complications of the technique.

Effect of laryngotracheal topical anesthesia on recurrent laryngeal nerve monitoring during thyroid Surgery

STUDY OBJECTIVE

Intraoperative neuromonitoring of the recurrent laryngeal nerve (RLN) is often used as an adjunct for RLN identification and preservation during thyroidectomies. Laryngotracheal anesthesia (LTA) with topical lidocaine reduces coughing upon emergence from anesthesia and in the immediate postoperative period; however, its use is prohibited with concerns that it could decrease the sensitivity of the intraoperative neuromonitoring. We hypothesize that there is no difference in measurements of nerve conduction made before and after LTA administration.

DESIGN

An observational study in which all patients were subjected to LTA administration was conducted. Recurrent laryngeal nerve threshold currents were measured before and after the intervention.

SETTING

Tertiary medical center operating room.

PATIENTS

Eighteen patients (total of 25 nerves at risk) with American Society of Anesthesiologists classes 1 to 3 undergoing thyroid surgery.

INTERVENTIONS

After the thyroid was removed and threshold currents at the RLN were obtained, LTA with endotracheal lidocaine was applied on the left and right side of the in situ endotracheal tube (2 cc of 4% lidocaine per side). Threshold currents were reassessed at 5 and 10 minutes after LTA administration.

MEASUREMENTS

Threshold currents (minimum stimulus current applied to the RLN required to generate a discernible electromyographic response at the vocal cords) were recorded along the RLN for a baseline at 5 and 10 mm from the insertion point of the RLN into the larynx. Threshold currents were reassessed at the same 2 positions on the RLN at 5 and 10 minutes after LTA administration. Differences in mean values, between threshold currents recorded at the 3 different times, at 2 positions on the RLN, were used to compare effects of LTA on nerve conduction.

MAIN RESULTS

There were no statistically significant differences when comparing threshold currents before and after LTA administration.

CONCLUSIONS

Laryngotracheal anesthesia had no significant effect on RLN nerve conduction in the period assessed.

Effect of Intracuff Lidocaine on Postoperative Sore Throat and the Emergence Phenomenon: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Postoperative sore throat and other airway morbidities are common and troublesome after endotracheal tube intubation general anesthesia (ETGA). We propose lidocaine as endotracheal tube (ETT) cuff inflation media to reduce the postintubation-related emergence phenomenon.

METHODS

We searched PubMed, EMBASE, and Cochrane databases systematically for randomized controlled trials (RCTs) that have investigated the outcome of intracuff lidocaine versus air or saline in patients receiving ETGA. Using a random-effects model, we conducted a meta-analysis to assess the relative risks (RRs) and mean difference (MD) of the incidence and intensity of relevant adverse outcomes.

RESULTS

We reviewed nineteen trials, which comprised 1566 patients. The incidence of early- and late-phase postoperative sore throat (POST), coughing, agitation, hoarseness, and dysphonia decreased significantly in lidocaine groups, with RRs of 0.46 (95% confidence interval [CI]: 0.31 to 0.68), 0.41 (95% CI: 0.25 to 0.66), 0.43 (95% CI: 0.31 to 0.62), 0.37 (95% CI: 0.25 to 0.55), 0.43 (95% CI: 0.29 to 0.63), and 0.19 (95% CI: 0.08 to 0.5), respectively, when compared with the control groups. The severity of POST also reduced significantly (mean difference [MD] -16.43 mm, 95% CI: -21.48 to -11.38) at 1 h and (MD -10.22 mm, 95% CI: -13.5 to -6.94) at 24 h. Both alkalinized and non-alkalinized lidocaine in the subgroup analyses showed significant benefits in emergence phenomena prevention compared with the control.

CONCLUSION

Our results indicate that both alkalinized and non-alkalinized intracuff lidocaine may prevent and alleviate POST and postintubation-related emergence phenomena.

Lidocaine for preventing postoperative sore throat

BACKGROUND

Sore throat is a common side-effect of general anaesthesia and is reported by between 30% and 70% of patients after tracheal intubation. The likelihood of a sore throat varies with the type, diameter, and cuff pressure of the endotracheal tube used. If intubation is essential, it may be helpful to give drugs prophylactically to alleviate postoperative sore throat. Local anaesthetics and steroids have been used for this purpose. This review was originally published in 2009 and was updated in 2015.

OBJECTIVES

The objective of this review was to evaluate the efficacy and any harm caused by topical and systemic lidocaine used prophylactically to prevent postoperative sore throat in adults undergoing general anaesthesia with endotracheal intubation.

SEARCH METHODS

We searched CENTRAL (The Cochrane Library 2013, Issue 9), MEDLINE (January 1966 to October 2013), and EMBASE (1980 to October 2013). We also contacted manufacturers and researchers in the field. The original search was undertaken in June 2007. We reran the search in February 2015 and found four studies of interest. We will deal with those studies when we next update the review.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) of topical and systemic prophylactic lidocaine therapy versus control (using air or saline) that reported on the risk and severity of postoperative sore throat as an outcome.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information, such as the risk of any adverse effects.

MAIN RESULTS

We included 19 studies involving 1940 participants in this updated review. Of those 1940 participants, 952 received topical or systemic lidocaine therapy and 795 were allocated to the control groups. Topical and systemic lidocaine therapy appeared to reduce the risk of postoperative sore throat (16 studies, 1774 participants, risk ratio (RR) was 0.64 (95% confidence interval (CI) 0.48 to 0.85), the quality of the evidence was low), although when only high-quality trials were included (eight studies, 814 participants) the effect was no longer significant (RR 0.71, 95% CI 0.47 to 1.09). Lidocaine given systemically in two studies (320 participants) did not reveal evidence of an effect (RR 0.44, 95% CI 0.19 to 1.05 ). The severity of sore throat as measured on a visual-analogue scale (VAS) was reduced by lidocaine therapy (six trials, 611 participants, (mean difference (MD) -10.80, 95% CI -14.63 to -6.98). The adverse effects of lidocaine were not reported in these studies, though toxicity is generally rare.

AUTHORS' CONCLUSIONS

In our revised systematic review, although the results of included studies show generally positive results, they should be interpreted carefully. The effect size of lidocaine appeared to be affected by study quality; drug concentration; route of administration; management of cuff pressure during anaesthesia; the included population; and the type of outcome measured.

Replacing a double-lumen tube with a single-lumen tube or a laryngeal mask airway device to reduce coughing at emergence after thoracic surgery: a randomized controlled single-blind trial

BACKGROUND

Coughing episodes occur frequently at extubation after thoracic surgery, and this may be due in part to the double-lumen tube (DLT). In this study, the DLT was replaced with either a single-lumen endotracheal tube (ETT) or a laryngeal mask airway (LMA) device or left in place, and the incidence of coughing at emergence was compared between the three groups.

METHODS

Fifty-eight adults scheduled for thoracic surgery with a DLT were included. Exclusion criteria were an anticipated difficult airway, obesity, and contraindication to the use of an LMA ProSeal™ (LMA-P). After surgery but before emergence, patients were randomized to having the DLT (1) removed and replaced by an LMA-P (LMA-P Group), (2) removed and replaced by an ETT (ETT Group), or (3) left in place (DLT Group). The primary outcome was the number of coughing episodes at extubation.

RESULTS

Among 184 patients screened, 124 did not meet inclusion criteria, and two patients, both in the ETT Group, were excluded after randomization, leaving 20, 18, and 20 patients in the LMA-P, ETT, and DLT Groups, respectively. There were fewer coughing episodes (median [quartiles]) in the LMA-P Group than in the DLT Group (0[0-1] vs 2[1-3], respectively; P = 0.01). In the DLT Group, 90% of patients coughed at least once. This incidence was not significantly different in the ETT Group (83%; P = 0.222) but was significantly reduced in the LMA-P Group (35%; P < 0.001). No patient had oxygen desaturation during airway exchange or at extubation. The incidence and severity of hoarseness and sore throat were similar in all groups.

CONCLUSION

Coughing at extubation after thoracic surgery can be reduced if the DLT is replaced by an LMA-P before emergence. The number of patients in this trial was too small to evaluate the risks associated with exchanging the airway device. This trial was registered at ClinicalTrials.gov: NCT00925613.

Nebulized ketamine decreases incidence and severity of post-operative sore throat

Background and Aims:

Post-operative sore throat (POST) occurs in 21-65% of patients. Ketamine used earlier as gargle for reducing POST has limitations. The aim of this study was to see if nebulised ketamine reduces POST.

Methods:

We conducted a prospective, randomised, placebo-control, and double-blind controlled trial. After written informed consent, 100 patients belonging to American Society of Anaesthesiologists physical status I-II in the age group 20-60 years, of either sex undergoing surgery under general anaesthesia (GA) were enrolled. Patients were randomised into two groups; group saline (S) received saline nebulisation 5.0 ml and group ketamine (K) received ketamine 50 mg (1.0 ml) with 4.0 ml of saline nebulisation for 15 min. GA was induced 10 min after completion of nebulisation in the patients. The POST and haemodynamic monitoring were done pre-nebulization, pre-induction, on reaching post-anaesthesia care unit, and at 2, 4, 6, 8, 12 and 24 h post-operatively. POST was graded on a four-point scale (0-3).

Results:

The overall incidence of POST was 33%; 23 patients (46%) in saline and 10 patients (20%) in ketamine group experienced POST (Fisher's exact P = 0.01). The use of ketamine nebulization attenuated POST at 2 h and 4 h post-operatively (P < 0.05). The primary outcome was incidence of POST at 4 h; 13 patients in group S versus 4 patients in group K (P = 0.03) experienced POST at 4 h. The moderate sore throat occurred in 6 patients in group S and none in group K at 2 h, post-operatively (P = 0.02).

Conclusion:

Ketamine nebulization significantly attenuated the incidence and severity of POST, especially in the early post-operative period, with no adverse effects.

Local airway anesthesia attenuates hemodynamic responses to intubation and extubation in hypertensive surgical patients

BACKGROUND

The aim of this study was to evaluate the effects of topical ropivacaine anesthesia on hemodynamic responses during intubation and extubation of hypertensive patients.

MATERIAL AND METHODS

One hundred fifty patients with hypertension ASA II-III were scheduled for noncardiac operations. Patients were divided into 3 groups: a control group receiving 5 ml saline, and 2 groups receiving topical anesthesia with 100 mg lidocaine or 37.5 mg ropivacaine. Hemodynamic responses, including blood pressure and heart rate (HR), were recorded at baseline (T0), before intubation (T1), during tracheal intubation (T2), 2 min after intubation (T3), upon eye opening on verbal commands (T4), during tracheal extubation (T5), and 2 min after extubation (T6). Patients were injected with urapidil 5 mg during intubation and extubation if their systolic blood pressure (SBP) was ≥160 mmHg or diastolic blood pressure (DBP) was ³90 mmHg, and esmolol 10 mg when HR was ≥90 bpm.

RESULTS

During extubation, the total dosages of urapidil and esmolol were significantly higher in the saline than in the lidocaine or ropivacaine groups, and were significantly lower in the ropivacaine than in the lidocaine group. At T2, SBP, SBP, MAP, and HR were lower in the lidocaine and ropivacaine groups than in the saline group, but the differences were not significant. From T4 to T6, SBP, DBP, MAP, and HR were significantly lower in the ropivacaine group than in the other 2 groups (P<0.05 each).

CONCLUSIONS

Topical lidocaine and ropivacaine anesthesia can effectively reduce hemodynamic responses during intubation, with ropivacaine better at inhibiting hemodynamic changes at emergence in hypertensive patients.