Postoperative sore throat: cause, prevention and treatment

Comparison between the standard method and the 30° curved tongue depressor-aided technique for insertion of a laryngeal mask airway: a randomized controlled trial

BACKGROUND

Laryngeal mask airway (LMA) has been increasingly used for airway management; however, LMA insertion can be difficult and cause adverse effects. Therefore, the rapid, safe, and effective insertion of LMA is necessary. This study aimed to compare the efficacy of the standard method with that of the 30° curved tongue depressor-aided technique for LMA insertion to determine the superior technique.

METHODS

This study included 154 patients aged 18-70 years (American Society of Anesthesiologists class I or II) scheduled for general anesthesia. The patients were randomly assigned to the standard LMA insertion group (Group C, n = 77) or the 30° curved tongue depressor-aided LMA insertion group (Group T, n = 77). The primary outcome evaluated was the first-attempt success rate. The secondary outcomes were the second-attempt success rate, insertion time, fiberoptic position grade, oropharyngeal leak pressure (OPLP), and adverse events.

RESULTS

The first-attempt success rate was significantly higher in Group T than in Group C (97.40% vs. 88.31%, P = 0.029). The second-attempt success rate (P = 0.209), insertion time (P = 0.340), fiberoptic position grade (P = 0.872), and OPLP (P = 0.203) were slightly improved in Group T; however, there was no statistical significance. Bleeding events were reduced in Group T than in Group C (6.49% vs. 14.29%); however, there was no statistical significance. The incidence of sore throat symptoms was significantly reduced in Group T than in Group C (5.19% vs. 15.58%, P = 0.035).

CONCLUSIONS

The curved tongue depressor-aided technique significantly improved the first-attempt success rate of LMA insertion and reduced the incidence of sore throat symptoms.

TRIAL REGISTRATION

KCT0004964; Registered at https://cris.nih.go.kr on April 27, 2020.

Comparative Efficacy of Intracuff 1% and 2% Alkalinized Lignocaine with Saline on Endotracheal Tube-Induced Hemodynamic Changes and Emergence Phenomena in Neurosurgical Patients

Introduction  Extubation is associated with hemodynamic changes and emergence phenomena leading to cough, sore throat, dysphonia, and dysphagia in the postoperative period. The aim of our study was to compare intracuff 2% alkalinized lignocaine with 1% alkalinized lignocaine and saline in reducing endotracheal tube induced emergence phenomena and haemodynamic changes at extubation in neurosurgical patients. Materials and Methods  In this randomized controlled study, 90 adult patients of either sex, scheduled to undergo neurosurgical procedures were randomly divided into three groups of 30 each to receive either 1% alkalinized lignocaine (AL1), 2% alkalinized lignocaine (AL2), or saline as cuff inflation media. Intracuff pressures and haemodynamic variables were noted intraoperatively and during emergence. The presence of postextubation cough, sore throat, dysphonia, and dysphagia were monitored until 24 hours postoperatively. Data were analyzed using Chi-square test and ANOVA. A p -value of less than 0.05 was considered significant. Results  The intracuff pressures were significantly less with alkalinized lignocaine as compared to saline, after 3 hours of induction. Post extubation, hemodynamic parameters and incidence of coughing and bucking at extubation were significantly less in Groups AL1 ( p  = 0.024) and AL2 ( p  = 0.02) as compared to saline. On assessment of laryngotracheal morbidity, the incidence of coughing was found to be significantly less with 2% alkalinized lignocaine as compared to saline ( p  = 0.021) at 1 hour after extubation. Sore throat was significantly less in Groups AL1 and AL2 as compared with saline at 1 hour ( p  = 0.008, 0.002 respectively) and 8 hours ( p  = 0.01 in both groups), and in Group AL2 versus saline at 24 hours ( p  = 0.044) after extubation. The incidence of dysphonia was significantly less in Groups AL1 and AL2 as compared with saline at 1 hour ( p  = 0.016, p  = 0.002) and 24 hours ( p  = 0.012 in both groups) and in Group AL2 versus saline at 8 hours (p  = 0.03) postoperatively. No significant differences were noted between 1% alkalinized lignocaine and 2% alkalinized lignocaine. Conclusion  Intracuff alkalinized lignocaine 1% and 2% were significantly better than saline in reducing coughing and bucking at extubation, post extubation haemodynamic changes and incidence of postoperative cough, sore throat, and dysphonia.

Pharyngolaryngeal Morbidity With the Laryngeal Mask Airway SupremeTM at Different Fiberoptic Bronchoscopy Grades: An Observational Study

OBJECTIVE

To assess whether the different fiberoptic bronchoscopy (FOB) grades of laryngeal mask airway (LMA) Supreme™ affects pharyngolaryngeal morbidity (PLM, including sore throat, dysphonia, pharyngoxerosis, and dysphagia) after general anesthesia.

METHODS

A total of 235 adult patients scheduled for elective laser lithotripsy undergoing general anesthesia with the placement of LMA Supreme™ were enrolled. The position of LMA Supreme™ was assessed by FOB and categorized into five grades. Meanwhile, patients were divided into four groups (grades A-D); none was assessed as grade E. We collected blinded data on PLM at 2 (H+2), 6 (H+6), and 24 hours (H+24) postoperatively. The incidence and severity of PLM as the primary outcome and incidence of PLM at three time points as a secondary outcome were compared.

RESULTS

The incidence of PLM was higher at 2 and 6 hours than at 24 hours; however, no significant difference was found between the incidence of PLM in the FOB groups. Furthermore, the severity of sore throat and dysphonia between groups were obviously differed at H+6 and H+24, but similar at H+2. The severity of postoperative pharyngoxerosis and dysphagia were similar between groups at three time points.

CONCLUSIONS

A positive association was found between the severity of postoperative sore throat and dysphonia and FOB grade after LMA Supreme™ placement. PLM secondary to placement of the LMA Supreme™ was short lasting.

The knowledge and skills of emergency department registered nursing staff at an academic hospital in South Africa, on endotracheal tube cuff manometry, before and after a training session

Introduction

Accurate management of endotracheal tube cuff pressure is essential to prevent patient morbidity and mortality. Due to increased length of stay of critically ill patients in emergency departments, it has become an increasingly important skill among Emergency Department nurses.

Methods

This prospective longitudinal interventional study was performed among registered nurses at the emergency departments in a Johannesburg Academic Hospital. The study aimed to determine their current knowledge and practical skills on endotracheal tube cuff manometry and assess the effectiveness of a training program. The training program was provided once, in the form of a narrated PowerPoint presentation developed by the researchers and involved theoretical and practical components. The participants' theoretical knowledge and practical skills were measured by using questionnaires and skill assessments. The theoretical and practical scores were compared pre- and post-training.

Results

Of the 63 registered nurses employed in the emergency departments, 95 % (60) participated in this study. 86 % reported having never received any formal training on endotracheal tube cuff manometry. Only 38.9 % used cuff manometry as standard practice and only 12.8 % checked it at appropriate 12-hourly intervals. The pre-training median score on theory was 4.5 (IQR=3.0) and improved to 7.0 (IQR=3.0) post-training. The maximum achievable score was 11 with a pre-training average of 41.8 % and post-training of 64.5 % (p = 0.001).The practical pre-training median score was 1.0 (IQR=8.0) and improved to 12.0 (IQR=2.0) post-training. The maximum achievable score was 12 with a pre-training average of 29.1 % and a post-training average of 93.3 % (p = 0.001).

Conclusion

This study showed inadequate knowledge and skills on endotracheal cuff pressure manometry among registered nurses in the emergency department. It also correlates with other evidence that supports the need for ongoing training programs. Our training program led to significant improvement among participants in both knowledge and practical skills. This training program was well received by participants and deemed to be practice changing. The recommendation after this study will be for South African emergency units to consider using this study and training material as a guide for annual in-service training.

Prediction of Postoperative Sore Throat in Patients After Day-case Surgery With General Anesthesia: A Retrospective Study

PURPOSE

Postoperative sore throat (POST) is a major complaint after day-case surgery. The objectives of this study were to investigate the risk factors for POST and develop a stratified nursing model for POST after day-case surgery.

DESIGN

This case-control study was conducted at Department of Anesthesiology of 1st Affiliated Hospital of Wenzhou Medical University in Wenzhou, Zhejiang, China.

METHODS

Anesthesia records and postanesthesia care files of adult patients undergoing day-case surgery with general anesthesia were reviewed. The primary outcome was the incidence of POST at 24 hours after day-case surgery or before discharge within 24 hours. Multivariate logistics regression was used to identify risk factors for POST. A nomogram was created to predict the probability of POST after day-case surgery.

FINDINGS

A total of 9,312 records were retrieved from June 1, 2021 to April 30, 2022, including 8,499 files in the training group and 813 files in the validation group. One thousand five hundred and twenty-five cases in the training group experienced POST. The independent risk factors for POST included: thyroid surgery (odds ratios [OR] = 22.42, 95% confidence intervals [CI]: 18.45 to 27.25), shorter thyromental distance (OR = 1.18, 95% CI: 1.06 to 1.30), smaller neck circumference (OR = 1.09, 95% CI: 1.06 to 1.11), duration of anesthesia (OR = 1.13, 95% CI: 1.04 to 1.22), female (OR = 1.66, 95% CI: 1.41 to 1.96), age (OR = 0.99, 95% CI: 0.99 to 1.00) and the presence of bloody sputum (OR = 8.33, 95% CI: 6.53 to 10.63). A nomogram that involved five factors was established to predict the probability of POST after day-case surgery. The area under the receiver operating characteristic curve in the training and validation groups was 0.77 and 0.81, respectively. The calibration curve demonstrated good consistency between the actual POST and the predicted probability.

CONCLUSIONS

The following variables are independently associated with POST: thyroid surgery, age approaching to 40 years old, female, shorter thyromental distance and smaller neck circumference, longer duration of anesthesia, and the presence of bloody sputum. A novel stratified nursing model is feasible for predicting the probability of POST.

Flurbiprofen in the subglottic space to prevent postoperative sore throat after cardiac surgery: A randomized double-blind study

STUDY OBJECTIVE

Postoperative sore throat (POST) and hoarseness are common complications of tracheal intubation. This study aims to evaluate the efficacy of flurbiprofen administered through the subglottic port of tracheal tubes to prevent POST after cardiac surgery.

DESIGN

Single-center, prospective, randomized, double-blind, placebo-controlled trial.

SETTING

Tertiary Care Referral University Hospital (Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome).

PATIENTS

Included 71 patients undergoing for elective cardiac surgery. Inclusion criteria were (a) age between 50 and 75 years, (b) NYHA class I or II, (c) surgery for myocardial revascularization or valve repair or replacement under cardiopulmonary bypass.

INTERVENTION

Patients were double blind randomized to receive flurbiprofen or saline in the subglottic port of the endotracheal tube (groups F and P). The solution was injected ten minutes after tracheal tube placement, ten minutes after ICU admission and ten minutes before tracheal tube removal.

MEASUREMENTS

The primary outcome was to assess the effect of topical flurbiprofen administered through the subglottic port of the tracheal tube to prevent post-operative sore throat (POST). The secondary outcomes were the presence of hoarseness safety and patient's subjective satisfaction with their recovery. We did not report any exploratory outcomes.

MAIN RESULTS

We analyzed 68 patients, 34 patients in each group. In group F, two patients complained of POST and hoarseness (5.9%), while all controls did. The two groups significantly differed in the severity scores (VAS and TPS for sore throat and HOAR for hoarseness) at all time points. In group P, patients reported mild to moderate symptoms that significantly improved or disappeared 36 h after tracheal tube removal. According to the multivariable model, hoarseness affected women less than men, in the control group (p = 0.002). None of the patients in either group reported any adverse effects.

CONCLUSIONS

Repeated administration of flurbiprofen through the subglottic port of tracheal tubes reduced the incidence of sore throat and hoarseness after cardiac surgery without evidence of complications.

Endoscopic treatment of subglottic stenosis with flexible bronchoscopy via laryngeal mask airway

OBJECTIVE

To evaluate the safety and efficacy of endoscopic treatment of subglottic stenosis with flexible bronchoscopy via laryngeal mask airway (LMA) approach.

METHODS

The records of all patients who underwent endoscopic surgery for subglottic stenosis (SGS) from November 2019 to January 2023 at an academic medical center were reviewed with attention to demographics, patient comorbidities, airway stenosis characteristics, operative time details, surgical complications, and post-operative course. All patients, >18 years old, with one or more surgeries for SGS using (LMA) for intraoperative airway management were included. Surgeries with suspension microlaryngoscopy were excluded. Patients with glottic stenosis or tracheotomy were excluded.

RESULTS

Thirty-five patients underwent 52 procedures meeting inclusion criteria. Mean age was 55 years (range 31-78, SD 13.3) and 33 patients (94%) were female. Mean BMI was 30.9 (range 18.4-60.5, SD 8.8). The most common etiology of stenosis was intubation injury in 17 patients (49%), followed by idiopathic in 13 patients (37%). Cotton-Meyer grade 3 (71-99% narrowing) was seen in 25 patients (71%). Mean anesthesia and surgical operative times were 75.9 min (SD 13.5 min) and 39.7 min (SD 11.0 min), respectively. Mean SpO2 nadir was 94.5% (SD 6.3%). No patients required intraoperative change to rigid laryngoscopy, intubation, or tracheotomy. There were no post-operative complications. Mean surgery-free interval was 12.2 months (SD 6.3).

CONCLUSION

Endoscopic treatment of subglottic stenosis with flexible bronchoscopy and spontaneous ventilation via LMA approach is a safe and effective option, especially in patients with limitations for rigid laryngoscopy and elevated BMI.

LEVEL OF EVIDENCE

Level Four (case series) Laryngoscope, 134:2672-2677, 2024.

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.

Use of K-Y Jelly on Throat Packs for Postoperative Sore Throat after Nasal Surgery: A Randomized Controlled Trial

Introduction  Postoperative sore throat (POST) is a fairly common side effect of general anesthesia. The K-Y jelly is a well-known lubricant used in many medical procedures. Objective  In this randomized study, we evaluated the use of throat packs soaked with K-Y jelly for POST outcomes in patients submitted to nasal surgery. Methods  The present double-blinded, randomized, controlled study included 140 ASA I-II patients undergoing nasal surgery under general anesthesia. Patients received either or K-Y jelly or water-soaked X-ray detectable throat packs fully inserted into the mouth to occlude the oropharynx. Results  Comparison between the studied groups regarding the severity of POST assessed by visual analog scale revealed significantly lower POST levels in the K-Y jelly group on recovery from anesthesia, and at 2, 4, and 6 hours postoperatively. Conclusions  The use of K-Y jelly-soaked throat packs was associated with less severe POST after nasal surgery.

Awake Nasal Fiberoptic Intubation in Lateral Position for Severely Obese Patients with Anticipated Difficult Airway: A Randomized Controlled Trial

BACKGROUND

Obesity is a well-recognized risk factor for difficult intubation. To safely manage and overcome airway challenges in severely obese patients with a suspected difficult airway, awake fiberoptic intubation is recommended. We aimed to investigate the utility of awake nasal fiberoptic intubation in severely obese patients with suspected difficult airway while positioning them in the lateral decubitus position.

METHODS

This randomized controlled trial compared lateral and supine positions for awake nasal fiberoptic intubation in severely obese patients with an anticipated difficult airway by assessing the success rate, time needed to secure the airway, peri-procedural adverse events, and postoperative satisfaction of patients.

RESULTS

Sixty patients with a median age of 37 [inter-quartile range (IQR): 29-44] years were included, of which 47 (78.3%) were females. The median body mass index (BMI) was 45.5 [IQR: 42.5-50.8] kg/m2. The success rate of fiberoptic intubation was 100% in both groups. The time needed to successfully secure the airway was 188 [148.8-228.8] seconds (s) in the lateral position, compared to 214.5 [181.8-280.5] s in supine position (p = 0.019). Intraprocedural cough was more common in the supine position group (n = 8; 26.7%), compared to the lateral position group (n = 3; 10%; p = 0.095). Postoperative sore throat was more common in the lateral position group (n = 12; 40%) compared to the supine position (n = 5; 16.7%; p = 0.045).

CONCLUSIONS

In conclusion, Intubation in the lateral position is a promising technique that is equivalent to the routine supine position during fiberoptic intubation. In fact, intubation in the lateral position took less time to successfully secure the airway.

Effect of superior laryngeal nerve block in alleviating sore throat after application of i-gel supraglottic airway: a randomized controlled trial

BACKGROUND

Postoperative sore throat (POST) is a common complaint after supraglottic airway device (SAD) application. Internal branch of the superior laryngeal nerve (iSLN) block has the potential to alleviate POST. The aim of this trial was to explore the effect of iSLN block in alleviating sore throat, as well as to identify the potential risk factors for POST after SAD insertion.

METHODS

One hundred thirty-four patients scheduled for elective gynecological surgery were randomized to either group T: tetracaine syrup (1%) for local lubrication on i-gel supraglottic device (n = 67) or group B: i-gel insertion with water based lubricant on it and followed by bilateral iSLN block (ropivacaine, 0.375%, 2 ml for each side) (n = 67). Under ultrasound guidance, iSLN was exposed below thyrohyoid membrane. The primary outcome was the intensity of sore throat at 6 h after surgery. In addition, POST score at 0.5 h and 24 h, the severity of postoperative swallowing discomfort, acoustic analysis and complications were measured.

RESULTS

Compared with tetracaine syrup for local lubrication, iSLN block resulted in a reduced intensity of POST at 0.5 h (P = 0.044, OR = 1.99, 95%CI 1.02 to 3.88) and 6 h (P < 0.001, OR = 5.07, 95%CI 2.53 to 10.14) after surgery, as well as less severity of swallowing discomfort (P < 0.001, OR = 2.21, 95%CI 1.63 to 2.99) and cough (P = 0.039, OR = 1.97, 95%CI 1.04 to 3.73). The patients after iSLN block presented lower jitter and shimmer value in acoustic analysis at 6 h after surgery (P < 0.001).

CONCLUSIONS

iSLN block was effective in alleviating POST, improving voice function, as well as reducing postoperative swallowing discomfort and coughing.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR2000037974) on 8th Sept 2020.

A Prospective Randomized Controlled Trial of the Effect of Maintenance of Continuous Cuff Pressures (20 cmH2O vs 30 cmH2O) on Postoperative Airway Symptoms in Laparoscopic Surgeries

INTRODUCTION

Recently, laparoscopic surgery has been used in many fields of surgery. It has been reported that cuff pressure becomes high during laparoscopic surgery. Increased cuff pressure may cause postoperative sore throat and hoarseness. Considering previous reports, we hypothesized that maintenance of a fixed low cuff pressure during laparoscopic surgery might be associated with low grades of postoperative sore throat and hoarseness.

METHODS

The participants were 100 patients between 20 and 80 years of age who were scheduled to undergo laparoscopic surgery lasting over 2 hours. Patients were randomly allocated to two groups with endotracheal tube cuff pressures fixed at 20 cmH2O (low-pressure group; LPG) and 30 cmH2O (high-pressure group; HPG). We evaluated mainly sore throat and hoarseness on postoperative day 1 using a visual analog scale (VAS; 0-10 cm). Statistical comparisons of values were performed using the unpaired t-test, Mann-Whitney U-test, and chi-square test with values of p < 0.05 considered statistically significant.

RESULTS

There were no significant differences in background characteristics between the two groups. Median postoperative scores for the LPG and HPG were 1 (interquartile range, 0-3) and 0 (0-2; p = 0.560) for sore throat and 2 (0-4) and 1 (0-3; p = 0.311) for hoarseness, respectively, and the differences were not significant.

CONCLUSION

The effects of maintenance of a fixed low cuff pressure and a fixed high cuff pressure on the degrees of postoperative sore throat and hoarseness after laparoscopic surgery were the same and the grades were low.

Alkalized lidocaine in a tapered cuff suppresses endotracheal tube-induced hemodynamic changes: a randomized controlled trial

PURPOSE

The use of an endotracheal tube (ET) cuff filled with alkalized lidocaine (AL) can suppress ET-induced emergence phenomena, such as hypertension, tachycardia and coughing, and postoperative sore throat (POST) and hoarseness (PH). The efficacy of intracuff lidocaine may vary depending on the cuff shape, but there has been no study on the effects of a tapered cuff filled with AL. We examined whether intracuff AL suppresses ET-induced emergence phenomena, POST and PH.

METHODS

Sixty-two patients were enrolled in this study and the patients were randomly allocated to a group in which the tapered cuff was filled with AL (Group AL) and a group in which the tapered cuff was filled with normal saline (Group S). The primary outcomes of this study were changes in mean blood pressure (MBP) and heart rate (HR) at extubation. MBP, HR and the number of coughs were recorded before and up to 10 min after extubation. The degree of POST and the incidences of POST and PH were recorded at 15 min, 2 h and 24 h after extubation.

RESULTS

Changes in MBP before extubation and HR before and after extubation were significantly lower in Group AL than in Group S (p < 0.025). The number of coughs at extubation and the incidence of PH at 2 h after extubation were significantly lower in Group AL than in Group S (p < 0.0001 and p = 0.014, respectively).

CONCLUSION

AL in a tapered cuff significantly suppresses ET-induced cardiovascular changes in MBP and HR.

Effects of Endotracheal Tube with Adhesive Superficial Laryngeal Electrodes for Intraoperative Nerve Monitoring on Laryngopharyngeal Complications during Thyroidectomy

The endotracheal tube (ETT) with laryngeal adhesive electrodes for intraoperative neural monitoring (IONM) may be related to laryngopharyngeal complications, such as postoperative sore throat (POST), hoarseness, and coughing. We aimed to evaluate the effects of the ETT with laryngeal adhesive electrodes for IONM on the occurrence of laryngopharyngeal complications during thyroidectomy. In this retrospective study, we included 176 patients who underwent thyroidectomy for thyroid cancer between September 2020 and February 2021. The patients were categorized into control (n = 108) and IONM (n = 68) groups. Patients in the IONM group were intubated with the ETT with surface electrodes. Characteristics of the patients and surgery, perioperative variables, and laryngopharyngeal complications, including POST, hoarseness, and cough, were evaluated. The severity and incidence of POST were comparable between the two groups on postoperative days 0, 1, and 2 (p = 0.103, 0.386, and 0.056, respectively). Furthermore, no significant differences were observed in the occurrence of postoperative hoarseness and cough between the groups. The ETT with laryngeal adhesive electrodes for IONM during thyroidectomy did not affect the incidence and severity of postoperative laryngopharyngeal complications, including POST, hoarseness, and cough. Further prospective, double-blinded, randomized clinical trials are required to gain a clearer understanding.

Deep Neuromuscular Block for Endolaryngeal Surgery: A Systematic Review and Meta-Analysis

OBJECTIVES

To determine the safety and efficacy of deep neuromuscular block (NMB) for endolaryngeal surgery.

DATA SOURCES

PubMed, Web of Science, Cochrane Library, Ovid Medline, Embase, China National Knowledge Infrastructure, Wanfang, VIP databases, and trial registry database.

METHODS

Inclusion criteria followed the PICOS principles: Participants, adults undergoing endolaryngeal surgery; Intervention, deep NMB performed during the surgery; Control, no-deep NMB performed; Outcomes, primary outcome: the incidence of clinically acceptable surgical conditions.

SECONDARY OUTCOME

the incidence of intraoperative complications (including vocal fold movement and coughing) and total incidence of postoperative complications [including postoperative residual curarization (PORC), postoperative sore throat (POST), and postoperative nausea and vomiting (PONV)]. Study design, randomized controlled trials (RCTs). Duplicate publications, editorials, letters, abstracts, and reviews were excluded.

RESULTS

Four articles with 242 patients were identified for analysis. The results indicated that compared with no-deep NMB, deep NMB provides a higher incidence of clinically acceptable surgical conditions (98.36% vs. 76.67%; relative ratio [RR] = 1.29, 95% CI: 1.07-1.56), a lower incidence of intraoperative complications (10.83% versus 37.16%; RR = 0.32; 95% CI: 0.21-0.49) (lower incidence of vocal fold movement [1.85% vs. 34%; RR = 0.08, 95% CI: 0.02-0.41] and coughing [15.53% vs. 38.78%; RR = 0.42, 95% CI: 0.27-0.66]). There were no differences in the overall incidence of postoperative complications (RR = 2.10, 95% CI: 0.12-36.40).

CONCLUSIONS

Based on current published evidence, deep NMB provides better surgical conditions with a higher incidence of clinically acceptable surgical conditions and a lower incidence of intraoperative complications (lower incidence of vocal fold movement and coughing) without increasing the overall incidence of postoperative complications.

LEVEL OF EVIDENCE

1 Laryngoscope, 133:2055-2065, 2023.

Uvular Necrosis: Day-to-Day Progression of a Rare Postoperative Complication

Uvular necrosis is a rare post-procedural complication thought to be caused by mechanical compression of the uvula during endotracheal intubation. We described the day-to-day progression of uvular necrosis after right shoulder acromioclavicular (AC) joint reconstruction. We present a case of a 22-year-old male who visited the emergency department after sustaining a right shoulder trauma. Diagnosis of a type V AC dislocation with total coracoclavicular ligament tear was established. On day one, after endotracheal intubation for the right shoulder AC joint reconstruction, the patient complained of severe throat pain that progressed to odynophagia, dysphagia, and choking. Examination revealed an erythematous uvula with well-demarcated necrotic tissue. He was managed conservatively with acetaminophen and ice chips. Day-to-day symptom progression description may guide physicians in managing postoperative uvular necrosis.

Slow advancement of the endotracheal tube during fiberoptic-guided tracheal intubation reduces the severity of postoperative sore throat

Although fiberoptic-guided tracheal intubation is a gentler method than using a direct laryngoscope, injury may occur owing to impingement between the distal edge of the endotracheal tube and the glottis. This study aimed to investigate the effects of endotracheal tube advancement speed during fiberoptic-guided intubation on airway symptoms postoperatively. We randomized patients scheduled for laparoscopic gynecological surgery to either Group C or S. When advancing the tube over the bronchoscope, the operator advanced the tube at a normal speed in Group C and at a slower speed in Group S. The speed in Group S was approximately half that in Group C. The target outcomes were the severity of postoperative sore throat, hoarseness, and cough. Patients in Group C experienced a more severe sore throat than those in Group S at 3 and 24 h postoperatively (p = 0.001 and p = 0.012, respectively). However, the severity of hoarseness and cough postoperatively were not significantly different between the groups. In conclusion, the slow advancement of the endotracheal tube during fiberoptic-guided intubation can reduce sore throat severity.

Effect of head and neck positions on tracheal intubation using a McGRATH MAC video laryngoscope: A randomised, prospective study

BACKGROUND

Different head and neck positions may affect video laryngoscopy in terms of laryngeal exposure, intubation difficulty, advancement of the tracheal tube into the glottis and the occurrence of palatopharyngeal mucosal injury.

OBJECTIVE

We investigated the effects of simple head extension, head elevation without head extension and the sniffing position on tracheal intubation using a McGRATH MAC video laryngoscope.

DESIGN

A randomised, prospective study.

SETTING

Medical centre governed by a university tertiary hospital.

PATIENTS

A total of 174 patients undergoing general anaesthesia.

METHODS

Patients were randomly allocated to one of three groups: simple head extension (neck extension without a pillow), head elevation only (head elevation with a pillow of 7 cm and no neck extension) and sniffing position (head elevation with a pillow of 7 cm and neck extension).

MAIN OUTCOMES

During tracheal intubation using a McGRATH MAC video laryngoscope in three different head and neck positions, we assessed intubation difficulty by several methods: a modified intubation difficulty scale score, time taken for tracheal intubation, glottic opening, number of intubation attempts, requirements for other manoeuvres (lifting force or laryngeal pressure) for laryngeal exposure and advancement of the tracheal tube into the glottis. The occurrence of palatopharyngeal mucosal injury was evaluated after tracheal intubation.

RESULTS

Tracheal intubation was significantly easier in the head elevation group than in the simple head extension (P = 0.001) and sniffing positions (P = 0.011). Intubation difficulty did not differ significantly between the simple head extension and sniffing positions (P = 0.252). The time taken for intubation in the head elevation group was significantly shorter than that in the simple head extension group (P < 0.001). A lifting force or laryngeal pressure was required less frequently for tube advancement into the glottis in the head elevation group than in the simple head extension (P = 0.002) and sniffing position groups (P = 0.012). The need for a lifting force or laryngeal pressure for tube advancement into the glottis was not significantly different between the simple head extension and sniffing positions (P = 0.498). Palatopharyngeal mucosal injury occurred less frequently in the head elevation group than in the simple head extension group (P = 0.009).

CONCLUSION

The head elevation position facilitated tracheal intubation using a McGRATH MAC video laryngoscope compared with a simple head extension or sniffing position.

TRIAL REGISTRY NUMBER

ClinicalTrials.gov (NCT05128968).

Reduction in postoperative sore throat by preoperative nebulization with dexmedetomidine, ketamine or saline: A prospective, randomized-controlled trial

Background and Aims

Postoperative sore throat (POST) is a minor but distressing complication following general anesthesia. The current literature on the effect of preoperative nebulization with dexmedetomidine, or ketamine on POST is, however, sparse. So, we compared the effect of preoperative nebulization with these drugs on POST.

Material and Methods

One hundred and thirty-two American Society of Anaesthesiology (ASA) grade I-II patients undergoing elective laparoscopic surgeries under general anesthesia were randomized into three equal groups: D, K, or C to receive dexmedetomidine, ketamine, or saline as preoperative nebulization, respectively. The primary objective was to compare the incidence and severity of POST, as inferred from the patient interviews at 2, 6, 12, 24-h postoperatively.

Results

Group D had a significantly lower incidence (29.5%) and severity (12: mild; 1: moderate) of POST compared to group K (54.5% [21: mild; 3: moderate]) and group C (56.8% [19: mild; 6: moderate]), at 2-h postoperatively. The same trend was observed at 6-h postoperatively (group D: 22.7% [9: mild; 1: moderate]); group K: (40.9% [17: mild; 1: moderate]); group C (50% [17: mild; 5: moderate]). The mean arterial pressure was significantly lower in group D at 15 min intraoperatively (84.09 mmHg, P = 0.018) and immediate postoperatively (97.60 mmHg, P = 0.034). The postoperative sedation, nausea, and vomiting was not statistically significant.

Conclusion

Preoperative nebulization with dexmedetomidine is effective in the reduction of the incidence and severity of early POST.

An anthropometric evidence against the use of age-based estimation of bodyweight in pediatric patients admitted to intensive care units

Age-based bodyweight estimation is commonly used in pediatric settings, but pediatric ICU patients often have preexisting comorbidity and resulting failure to thrive, hence their anthropometric measures may be small-for-age. Accordingly, age-based methods could overestimate bodyweight in such settings, resulting in iatrogenic complications. We performed a retrospective cohort study using pediatric data (aged < 16 years) registered in the Japanese Intensive Care Patient Database from April 2015 to March 2020. All the anthropometric data were overlaid on the growth charts. The estimation accuracy of 4 age-based and 2 height-based bodyweight estimations was evaluated by the Bland-Altman plot analysis and the proportion of estimates within 10% of the measured weight (ρ10%). We analyzed 6616 records. The distributions of both bodyweight and height were drifted to the lower values throughout the childhood while the distribution of BMI was similar to the general healthy children. The accuracy in bodyweight estimation with age-based formulae was inferior to that with height-based methods. These data demonstrated that the pediatric patients in the Japanese ICU were proportionally small-for-age, suggesting a special risk of using the conventional age-based estimation but supporting the use of height-based estimation of the bodyweight in the pediatric ICU.

High incidence rate of postoperative sore throat in intubated children at Northwest Amhara Comprehensive Specialized Hospitals, Ethiopia. A multicenter study

Background

Postoperative sore throat is the most frequent complication in pediatric patients after general anesthesia. This study aimed to investigate the incidence of postoperative sore throat in patients undergoing general anesthesia with tracheal intubation or laryngeal mask airway.

Methods

A hospital-based multicenter prospective observational cohort study was conducted. Proportional allocation was done with a total of 424 patients from March 1 to June 30, 2022. The information was entered into the Epi-Data software version 4.6 and analyzed with Stata 14. Socio-demographic, surgical, and anesthetic-related characteristics were analyzed using descriptive statistics. A p-value of less than 0.2 was the cutpoint of bivariate logistic regression analysis, and p-values of less than 0.05 were regarded as statistically significant in multivariate logistic regression to determine the presence and strength of association between independent variables and postoperative sore throat.

Results

A total of 411 patients were included in this study, with a response rate of 96.9%. The overall proportion of patients who developed postoperative sore throat was 45% (95% CI: 40.18-49.84). Patients who had anesthesia for more than two hours (AOR = 8.23: 95% CI = 4.08-16.5), those who were intubated by undergraduate anesthesia students (AOR = 2.67: 95% CI = 1.53-4.67), and those who had been intubated using tracheal tube (AOR = 2.38: 95% CI = 1.15-4.92) were significantly associated with the level of postoperative sore throat.

Conclusions and recommendations

We concluded that intubated children with ETT have a high incidence of post-operative sore throat. Tracheal tube usage, intubation by undergraduate students, and more than two hours of anesthesia duration were associated factors. The incidence of sore throat can be decreased with the use of a laryngeal mask airway, intubation by a senior anesthetist, and shortening of anesthesia time.

Incidence of Postoperative Sore Throat and Associated Factors Among Pediatric Patients Undergoing Surgery Under General Anesthesia at Hawassa University Comprehensive Specialized Hospital, a Prospective Cohort Study

Background

Postoperative sore throat is one of the common postoperative complications following general anesthesia. Postoperative sore throat causes decreased patient satisfaction, and it affects patients' well-being after surgery, thus identifying its incidence and predictors helps to distinguish the preventable causes of postoperative sore throat. This study aimed to assess the incidence and associated factors of postoperative sore throat among pediatric patients undergoing surgery under general anesthesia at Hawassa university comprehensive specialized hospital.

Methods

A prospective cohort study was conducted among children in the age range 6-16 years old who underwent emergency and elective surgical procedures under general anesthesia. Data were entered and analyzed using SPSS version 26 software packages. Univariate and multivariate analyses were performed to investigate the independent predictors. The presence and severity of postoperative sore throat were assessed by using a four-point categorical pain scale at the 2nd, 6th, 12th, and 24th-hour postoperative time.

Results

A total of 102 children were recruited in this study, from which 27 children (26.5%) complained of sore throat postoperatively. This study found that endotracheal intubation (P value: 0.030; AOR: 3.155; 95% CI [1.114-8.933]) and several attempts greater than one (P value: 0.027 and AOR: 4.890; 95% CI: [1.203-19.883]) had statistically significant association with a postoperative sore throat.

Conclusion

The overall incidence of postoperative sore throat was 26.5%. Endotracheal intubation and the number of attempts greater than one were independent factors that were significantly associated with the occurrence of postoperative sore throat in this study.

Combined acupuncture-medicine anesthesia used in thyroid surgery: A systematic review and meta-analysis

BACKGROUND

Combined acupuncture-medicine anesthesia (CAMA) is extensively used in thyroid surgery in China. We conducted a systematic review and meta-analysis to assess the efficacy and safety of CAMA.

METHODS

We searched the China National Knowledge Infrastructure (CNKI), VIP database, WanFang database, PubMed, EMBASE, and the Cochrane Library for relevant literature. The term of literature was published before April 18, 2020, and there were no restrictions on publication language, region, or publication year. The inclusion criteria included a randomized controlled trial (RCT) of acupuncture combined with cervical plexus anesthesia. We used RevMan5.3 software for data analysis. If the chi-square test showed no significant heterogeneity (P > .10, I2 < 50%), we used the fixed-effect model to calculate risk ratio (RR) and mean difference. Otherwise, the random-effects model was used.

RESULTS

Overall, 18 RCTs involving 1211 patients were included in the study. The anesthesia significant rate (ASR) in the transcutaneous electrical acupoint stimulation (TEAS) plus cervical plexus block anesthesia (CPBA) and electroacupuncture (EA) plus CPBA groups was significantly higher compared with the CPBA group (TEAS + CPBA: P < .001; EA + CPBA: P < .001). The pooled effect values of the intraoperative heart rate (HR) and mean arterial pressure (MAP) were significantly lower in both the TEAS + CPBA and EA + CPBA groups relative to the control group (HR: P = .05, P < .001; the MAP: P = .002, P < .001; respectively). Moreover, the postoperative adverse reaction was markedly lower in the experimental group than in the control group (RR = 0.30, P < .001), and there was no heterogeneity between the two groups (P = .71, I2 = 0%).

CONCLUSION

Combined acupuncture-medicine anesthesia significantly increases the anesthesia significance rate, reduces the intraoperative heart rate, and blood pressure, and reduces the incidence of postoperative adverse reactions. However, more high-quality future studies should be conducted to validate the efficacy and safety of acupuncture combined anesthesia further.

A Randomized Comparison of Effects of Budesonide Spray and K-Y Gel as an Endotracheal Tube Cuff Lubricant on Incidence of Postoperative Sore Throat

PURPOSE

Postoperative sore throat (POST) is a frequent postoperative complication. Pre-induction budesonide inhalation is effective in POST prevention. However, it requires inhaler equipment and patient cooperation. Budesonide spraying on the endotracheal (ETT) cuff is simple and can be performed on most patients requiring endotracheal intubation. This study aims to compare the effects of budesonide spray and K-Y gel as an ETT cuff lubricant on the incidence and severity of POST.

DESIGN

Randomized and triple-blinded study.

METHODS

One hundred patients undergoing elective non-cardiac surgery were randomly allocated into the budesonide group (n = 50) and the K-Y gel group (n = 50). In the budesonide group, 200 mcg of budesonide was sprayed on the cuff of the ETT. For the K-Y gel group, the ETT cuff was lubricated with K-Y gel. A visual analog scale was used to assess the severity of POST at 2, 6, and 24 hours after surgery. Other complications of tracheal intubation and adverse effects of budesonide were also recorded.

FINDINGS

Compared to the K-Y gel group, the budesonide group had a significantly lower overall incidence of POST (30% versus 54%, P = .032) and reduced the risk of POST by 24% (relative risk reduction = 24%, 95% CI, 5.23-42.77, P = .012) as well as the incidence of hoarseness (8.6% vs 34%, P = .001) and cough (0% vs 8%, P = 0.041). No incidence of drug-related side effects was reported in both groups.

CONCLUSIONS

Spraying budesonide on the ETT cuff significantly reduces the incidence and severity of POST.

Gargling with ketamine preoperatively decreases postoperative sore throat after endotracheal intubation in middle ear surgeries: A prospective randomized control study

Postoperative sore throat (POST) is the eighth most common side effect in the postoperative period. Though it is considered as a minor side effect, it can lead to significant discomfort for the patient. Increased morbidity due to postoperative sore throat could have a big impact on outcomes with an increased economic burden to the nation. To determine the efficacy of ketamine gargle on a postoperative sore throat, we compared ketamine gargle with a normal saline gargle. Furthermore, we studied their efficacy on postoperative cough and hoarseness of voice. We randomly allocated 60 patients of ASA-I and II into two groups equally in patients posted for middle ear surgeries under general anaesthesia. Patients of the group- K were asked to gargle with 40 mg ketamine mixed with 29 ml normal saline preoperatively. Group- C patients were given 30 ml normal saline to gargle. Airway manipulation in all patients was done by senior anesthesiologists in the operating room. Patients were observed and interviewed at 1 h, 6 h, and 24 h after extubation for postoperative sore throat, cough, and hoarseness of voice. In the control group, the incidence of postoperative sore throat at 1 h, 6 h, and 24 h was 50%, 43.3%, and 36.7% respectively. When we compared the incidence in the ketaminegroup (Group-K) with the control group it showed that they were significantly lower (p-value ≤ 0.05) at all three observation points. On the other hand, ketamine gargle has no significant protective effect on the severity of postoperative sore throat, cough, and hoarseness of voice. Ketamine gargle in this study, showed significantly effective in attenuating postoperative sore throat in patients undergoing tracheal intubation for elective surgeries.

Efficacy of laryngeal mask airway against postoperative pharyngolaryngeal complications following thyroid surgery: a systematic review and meta-analysis of randomized controlled studies

This meta-analysis aimed at investigating the effectiveness of laryngeal mask airway (LMA) against postoperative pharyngolaryngeal complications after thyroidectomy. MEDLINE, Cochrane Library, google scholar, and EMBASE databases were searched from inception through February, 2021, for randomized controlled trials (RCTs) comparing the incidence of pharyngolaryngeal complications following the use of LMA or endotracheal tube (ETT). Pooled results from seven RCTs involving 600 patients showed an association of LMA with a reduced risk of postoperative sore throat (POST) at 24 h [risk ratio (RR) 0.75, p = 0.006, four trials], but not at 1 h and 48 h after thyroidectomy. POST severity and hoarseness risk were lower in the LMA group than the ETT group at 1 h, 24 h, and 48 h (all p < 0.05). Nevertheless, hoarseness severity was lower in the LMA group only at postsurgical 48 h [standardized mean difference = - 0.35, p = 0.008, three trials]. Moreover, the risk of emergence cough was lower in patients using LMA than those receiving ETT (RR = 0.14, p = 0.002, two trials). The two groups did not differ in the severity of dysphagia at postoperative 1 h, 24 h, and 48 h. This meta-analysis showed that LMA may be associated with fewer pharyngolaryngeal complications compared to ETT without airway impacts. The limited number of included studies warrants further research to support our findings.

Comparison of the effects of sevoflurane and desflurane on the severity score of postoperative pain and discomfort after thyroidectomy: A prospective, double-blinded, randomized controlled study

BACKGROUND

Thyroidectomy is performed under general anesthesia using inhaled anesthetics such as sevoflurane or desflurane in many cases. The objective of this study was to investigate whether the incidence of postoperative pain and discomfort after thyroidectomy differed with the type of inhaled anesthetic.

METHODS

Eighty-one female patients who underwent thyroidectomy were randomly assigned to the Sevo group (n = 42) or the Des group (n = 39). On the day of surgery and on the first, third, and seventh days after surgery, one registered nurse in charge of the entire questionnaire survey conducted the questionnaire assessment through face-to-face interviews or phone calls with the patients. The questionnaire evaluated the severity scores for seven items (sore throat, wound pain, nausea and vomiting, dizziness, occipital headache, posterior neck pain, and shoulder pain) regarding postoperative pain and discomfort experienced by patients and assessed which of these seven items caused the greatest discomfort to the patient on each day.

RESULTS

Except for the severity score for dizziness on the day of surgery, the severity scores of postoperative pain and discomfort experienced by patients on the day of surgery and on the first, third, and seventh days after surgery showed no statistically significant differences between the two groups. In addition, on the day of surgery and on the first, third, and seventh days after surgery, patients reported that sore throat caused the greatest discomfort.

CONCLUSION

In patients undergoing thyroidectomy under general anesthesia using sevoflurane or desflurane, except for dizziness on the day of surgery, no other manifestation of postoperative pain and discomfort was influenced by the type of inhaled anesthetic. Moreover, after thyroidectomy, postoperative sore throat caused the greatest discomfort to patients from the day of surgery to the seventh day after surgery.

Right displacement of trachea to reduce right bronchial misplacement of left double lumen tube: a prospective, double-blind, randomized study

Background

Misplacement of double-lumen endobronchial tubes (DLTs) during bronchial intubation, especially when bronchoscopy guidance is not applicable, threatens effective lung isolation and brings about airway injury during reposition. We aimed to examine whether a novel maneuver called right tracheal displacement (RTD) can reduce left-sided DLT misplacement during first-attempt intubation without bronchoscopy guidance.

Methods

Patients that underwent thoracic surgeries requiring one-lung ventilation during November 2020 to January 2021 were recruited and randomized into control and RTD group, with 54 cases in each group. The primary outcomes included the incidence of DLT misplacement and the time to complete desired bronchial intubation. The secondary outcomes included mucosal injury, sore throat and hoarseness upon emergence and at 24 h post-operatively.

Result

The incidence of DLT misplacement in RTD group was significantly lower compared to control group (0% vs. 16.7%) The time to complete bronchial intubation was also significantly shortened in RTD group compared to control (52.88 ± 9.36 s vs. 63.04 ± 20.02 s). The incidence of mucosal injury, sore throat and hoarseness were comparable between two groups.

Conclusion

RTD maneuver can effectively improve the success rate of first-attempt proper DLT positioning and shorten the time required by bronchial intubation.

Trial registration

This prospective, double-blind, randomized study has completed the registration of the Chinese Clinical Trial Center at 2/11/2020 with the registration number ChiCTR2000040212. It was conducted from 26/11/2020 to 31/7/2021 in third affiliated hospital of Sun Yat-sen university.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-022-01850-y.

Comparison of the supraglottic airway device BlockBusterTM and laryngeal mask airway Supreme in anaesthetised, paralyzed adult patients: a multicenter randomized controlled trial

BACKGROUND

This multicenter prospective, randomized controlled clinical trial compared the clinical performance of supraglottic airway device (SAD) BlockBuster^TM and laryngeal mask airway (LMA) Supreme for airway maintenance in anesthetized, paralyzed adult patients.

METHODS

A total of 651 adult patients scheduled for elective surgery in 13 hospitals were randomly allocated into BlockBuster group (n = 351) or Supreme group (n = 300). The primary outcome was oropharyngeal leak pressure (OLP). Duration and ease of insertion, fiberscopic view of positioning, airway manipulations, and complications were also assessed.

RESULTS

The OLP was significantly higher in BlockBuster group compared with Supreme group (29.9 ± 4.2 cmH₂O vs 27.4 ± 4.3 cmH₂O, p < 0.001). Success rate of insertion at the first attempt (90.2% vs 85.1%, p = 0.027), rate of optimal fiberscopic view (p = 0.002) and satisfactory positioning of SAD (p < 0.001) were significantly increased in BlockBuster group.

CONCLUSIONS

Both SAD BlockBuster^TM and LMA Supreme are safe, effective, and easy-to-use devices for airway maintenance in anesthetized, paralyzed adult patients, but the SAD BlockBuster^TM is superior to LMA Supreme in terms of OLP, success rate at the first attempt, and fiber-optic view of positioning.

TRIAL REGISTRATION

The trial is registered at www.chictr.org.cn (ChiCTR-ONC-16009105).

ED50 value of remifentanil in inhibiting coughing during extubation in children with snoring

Objective: This study aimed to determine the effective dose 50% (ED50) value of remifentanil in inhibiting coughing during extubation in children with snoring.

Methods: The subjects were children who scored a grade I in the American Society of Anesthesiology (ASA) metric and who were undergoing tonsillectomy (with or without adenoidectomy) under general anesthesia. Using Dixon’s up-and-down sequential method, the initial infusion rate of remifentanil was 0.06 μg/kg/min, and the difference between the infusion rates of the two adjacent groups was 0.01 μg/kg/min. If a child had no cough response during extubation, the infusion rate for the next child was reduced by 0.01 μg/kg/min. If that child had cough response, the infusion rate for the next child was increased by 0.01 μg/kg/min, and the test was terminated when seven pairs of children with positive-negative alternating results were obtained. The ED50 value and its 95% confidence interval (CI) were calculated by probit regression. The times for extubation, awakening, agitation, and respiratory complications after extubation were compared between the two groups.

Results: 1) The ED50 value of a continuous infusion of remifentanil required to inhibit the cough response of children during extubation was 0.042 μg/kg/min, and the 95% confidence interval was 0.025–0.062 μg/kg/min. 2) The total dosage and infusion rate of remifentanil in the cough suppression group were higher than those in the cough group (p &lt; 0.05), but the differences in the times for extubating and awakening between the two groups were not statistically significant (p &gt; 0.05). 3) There was no correlation between the infusion rate of remifentanil and the time for extubating and awakening in the cough suppression group; the r values were 0.13 and 0.12, respectively, and p &gt; 0.05. 4) The differences in postoperative respiratory complications between the two groups were not statistically significant (p &gt; 0.05).

Conclusion: The ED50 value of a continuous infusion of remifentanil required to inhibit the cough response of children during extubation after tonsillectomy (with or without adenoidectomy) was 0.042 μg/kg/min, and a low-dose infusion of remifentanil does not affect the times for awakening and extubating in children.

Effects of bevel direction of endotracheal tube on the postoperative sore throat when performing fiberoptic-guided tracheal intubation: A randomized controlled trial

BACKGROUND

During fiberoptic-guided tracheal intubation, impingement between the distal tip of the endotracheal tube and the airway tissue can cause difficulties in tube insertion or tissue damage during the tube advancement over the bronchoscope. This randomized controlled study aimed to investigate the effects of the endotracheal tube's bevel direction on the complications associated with airway injury when performing fiberoptic-guided tracheal intubation.

METHODS

The study subjects were divided into 2 groups: L (control) and D (study). When advancing the tube over the bronchoscope, the tube's bevel was facing the patients' left in Group L and the dorsal direction in Group D. According to the degree of resistance at the time of tube advancement, the insertion score was graded in 3 stages; the severity of the patients' sore throat and hoarseness was evaluated and recorded postoperatively.

RESULTS

The severity of postoperative sore throat was higher in Group L than in Group D 3 hours and 24 hours after surgery. (P = .008, P = .023, respectively). The tube insertion score was comparable between the groups. The severity of postoperative hoarseness did not vary significantly between the groups.

CONCLUSION

Endotracheal tube insertion with the bevel facing the dorsal direction of the patient during fiberoptic-guided tracheal intubation reduced the severity of postoperative sore throat in patients undergoing laparoscopic gynecologic surgery.

The effectiveness of acupuncture point stimulation for the prevention of postoperative sore throat: A meta-analysis

BACKGROUND

Enhanced recovery pathways can be further improved for postoperative sore throat (POST) that occurs after surgery under general anesthesia. Medications have shown some effectiveness in preventing POST, but acupuncture or related techniques with better safety and lower cost can be used as an alternative or adjuvant therapy to treat perioperative symptoms by stimulating acupuncture point (acupoint). Therefore, we aimed to conduct a meta-analysis to assess whether acupoint stimulation helps patients prevent POST in adults undergoing tracheal intubation for general anesthesia.

METHODS

Publications in PubMed, the Cochrane Central Register, ScienceDirect, and ClinicalTrial.gov were surveyed from January 2000 through August 2020. Studies that compared interventions between true acupoint stimulation and no or sham acupoint stimulation were included. The primary outcomes were the incidence and severity of POST at 24h.

RESULTS

Four randomized control trials and 1 comparative study involving 1478 participants were included. Compared with the no or sham acupoint stimulation, the true acupoint stimulation was associated with a reduced incidence (risk ratio, 0.32; 95% confidence interval (CI), 0.18-0.55; P < .001) and decreased severity (standardized mean difference, -2.79; 95% CI, -4.59 to - 0.99; P = .002) of POST. There were no significant adverse events related to acupoint stimulation. The finding for POST was assured by subgroup, sensitivity, and trial sequential analyses.

CONCLUSIONS

Acupoint stimulation may reduce the occurrence of POST. It can be considered as one of nonpharmacological methods to prevent POST in enhanced recovery pathways. Further rigorous studies are needed to determine the effectiveness of acupoint stimulation.

Development of a nomogram for prediction of postoperative sore throat in patients under general anaesthesia: a single-centre, prospective, observational study

OBJECTIVES

Postoperative sore throat (POST) is very common in patients under general anaesthesia. However, there is no effective clinical predictive model for reducing its occurrence. The objective of this study was to estimate the risk factors for POST in patients after general anaesthesia by designing a nomogram.

DESIGN

A prospective study.

SETTING

This study was conducted in a large tertiary hospital.

PARTICIPANTS

Patients aged 18-85 years old who received general anaesthesia with either an endotracheal tube or supraglottic airway and of American Society of Anesthesiologists classification level Ⅰ-III.

RESULTS

A total of 442 patients were enrolled in this study, with a POST incidence of 44.1%. The results showed that younger age (≤55 years), surgical site (head and neck surgery), duration of anaesthesia (≥4 hours) and history of chronic pharyngitis were independent risk factors for POST in general anaesthesia patients. Receiver operating characteristic (ROC) curves and calibration curves were used to evaluate the nomogram. The area under the ROC curve was 0.784 and the C-index was 0.779.

CONCLUSION

A nomogram combining age, surgical site, duration of anaesthesia and history of chronic pharyngitis is potentially useful in predicting POST under general anaesthesia.

TRIAL REGISTRATION NUMBER

ChiCTR-ROC-17013258; Post-results.

Efficacy and Safety of Flexible Laryngeal Mask Ventilation in Otologic Surgery: A Retrospective Analysis

Background

Flexible laryngeal mask airways (FLMAs) ventilation have been widely used as airway devices during general anesthesia, especially in otologic surgery. However, the current literature reports that the clinical success and failure rates for FLMA usage are quite different, and there remains a paucity of data regarding factors associated with FLMA failure and complications related to FLMA usage.

Purpose

To evaluate the success and failure rates of FLMA usage in otologic surgery, the factors associated with FLMA failure and complications related to FLMA usage.

Patients and Methods

All patients who underwent otologic surgery, including middle ear and mastoid procedures, under general anesthesia at a large tertiary general hospital from 2015 to 2019 were reviewed. The primary outcome was the FLMA failure rate, defined as any airway event requiring device removal and tracheal intubation, including primary and secondary failure. The secondary outcomes were specific clinical factors, including patient sex, age, weight, American Society of Anesthesiologists (ASA) classification, body mass index (BMI) and duration of surgery, which were analyzed as related risk factors.

Results

Among 5557 patients with planned FLMA use, the final success rate was 98.5%. Sixty-seven percent of the failures occurred during initial introduction of the FLMA, 8% occurred after head and neck rotation, and 25% occurred during the procedures. Two independent clinical factors associated with FLMA failure were male sex and age. Respiratory complications were observed in 0.61% of patients, and the rate of severe nerve and tissue damage associated with FLMA use was 0.05.

Conclusion

This study demonstrates a high success rate of 98.5% for FLMA use in adults undergoing otologic surgery with rare adverse airway events and injuries complications. Two independent risk factors require attention and thorough and accurate management is necessary for every clinician.

Endotracheal tube cuff pressure during laparoscopic bariatric surgery: highs and lows

Background: Gastric calibration tubes (GCTs) are a unique component of bariatric surgery. This study aimed to assess changes in the endotracheal tube (ETT) cuff pressure during laparoscopic bariatric surgery.Methods: This was a prospective observational study consisting of 124 American Society of Anesthesiologists class I–III morbidly obese patients (body mass index > 40 kg/m2) undergoing elective laparoscopic bariatric surgery under general anesthesia. The baseline ETT cuff pressure was 28 cmH2O. Cuff pressure, peak airway pressure, and hemodynamic changes were observed during various steps of bariatric surgery. Immediate postoperative complications during the first 24 h were recorded. Results: ETT cuff pressure increased significantly from the baseline (28 cmH2O) after insertion of GCT (36.3 ± 7.3 cmH2O) and creation of carboperitoneum (33.3 ± 3.8 cmH2O). Cuff pressure decreased significantly on GCT removal (24.0 ± 3.0 cmH2O) and release of carboperitoneum (24.7 ± 3.0 cmH2O). Peak airway pressure increased from the initial baseline value of 25.1 ± 3.1 to 26.5 ± 4.5 after GCT insertion, creation of carboperitoneum (32.6 ± 4.4), attainment of reverse Trendelenburg position (32.3 ± 4.0), and subsequent return to supine position 32.5 ± 4.8.Conclusions: The endotracheal cuff pressure significantly varies during the intraoperative period. Routine monitoring and readjustment of cuff pressure are advisable in all laparoscopic bariatric surgeries to minimize the possibility of postoperative complications.

Mucosa-Like Conformal Hydrogel Coating for Aqueous Lubrication

Mucosa is a protective and lubricating barrier in biological tissue, which has a great clinical inspiration because of its slippery, soft, and hydrophilic surface. However, mimicking mucosal traits on complex surface remains an enormous challenge. Herein, a novel approach to create mucosa-like conformal hydrogel coating is developed. A thin conformal hydrogel layer mimicking the epithelial layer is obtained by first absorbing micelles, followed by forming covalent interlinks with the polymer substrate via interface-initiated hydrogel polymerization. The resulting coating exhibits uniform thickness (≈15 µm), mucosa-matched compliance (Young's modulus = 1.1 ± 0.1 kPa) and lubrication (coefficients of friction = 0.018 ± 0.003), robust interfacial bonding against peeling (peeling strength = 1218.0 ± 187.9 J m^-2 ), as well as high water absorption capacity. It effectively resists adhesion of proteins and bacteria without compromising biocompatibility. As demonstrated by an in vivo cynomolgus monkey model and clinical trial, applications of the mucosa-like conformal hydrogel coating on the endotracheal tube significantly reduce intubation-related complications, such as invasive stimuli, mucosal lesions, laryngeal edema, inflammation, and postoperative pain. This work offers a promising prototype for surface decoration of biomedical devices and holds great prospects for clinical translation to enable interventional operations with minimally invasive impacts.

Risk Factors for Postoperative Sore Throat After Nasotracheal Intubation

OBJECTIVE

Postoperative sore throat is relatively frequent complication after orotracheal intubation. However, there are few reports about postoperative sore throat in nasotracheal intubation. In this retrospective study, we investigated the risk factors of postoperative sore throat in nasotracheal intubation.

METHODS

Anesthesia records of patients 16 to 80 years of age who underwent nasotracheal intubation were included. Patients underwent oral and maxillofacial surgery from February 2015 until September 2018. Airway device (Macintosh laryngoscope, Pentax-AWS, or McGRATH video laryngoscope, or fiberoptic scope), sex, age, height, weight, American Society of Anesthesiologists classification, intubation attempts, duration of intubation, intubation time, tube size, and fentanyl and remifentanil dose were investigated. Fisher exact test, Wilcoxon rank sum test, Welch t test, and Steel-Dwass multiple test were used, and a multivariable analysis was performed using stepwise logistic regression to determine the risk factors of postoperative sore throat.

RESULTS

A total of 169 cases were analyzed, and 126 patients (74.6%) had a postoperative sore throat. Based on the univariate analysis of the data, 12 factors were determined to be potentially related to the occurrence of a postoperative sore throat. However, after evaluation using stepwise logistic regression analysis, the 2 remaining variables that correlated with postoperative sore throat were airway device (P &lt; .05) and intubation attempts (P = .04). In the model using logistic regression analysis, the fiberoptic scope had the strongest influence on the incidence of sore throat with reference to Pentax-AWS (odds ratio = 5.25; 95% CI = 1.54-17.92; P &lt; .05).

CONCLUSION

Use of a fiberoptic scope was identified as an independent risk factor for postoperative throat discomfort. Compared with direct laryngoscopy and other video laryngoscopes, the use of a fiberoptic scope had a significantly higher incidence of sore throat.

Comparative Efficacy of 6 Topical Pharmacological Agents for Preventive Interventions of Postoperative Sore Throat After Tracheal Intubation: A Systematic Review and Network Meta-analysis

BACKGROUND

Topical pharmacological agents typically used to treat postoperative sore throat (POST) after tracheal intubation include nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, lidocaine, Glycyrrhiza (licorice), and N-methyl-d-aspartate (NMDA) receptor antagonists (including ketamine and magnesium). However, the optimal prophylactic drug remains elusive.

METHODS

The literature published before September 8, 2019 was searched on the PubMed, the Embase, the Web of Science, and the Cochrane Library. Randomized controlled trials (RCTs) covering topical prophylactic medications for patients with POST were included. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was used to assess the quality of evidence. The primary outcome is the risk of POST. Combining both direct and indirect evidence, a network meta-analysis was performed to assess odds ratios (ORs) between the topical pharmacological agents and surface under the cumulative ranking (SUCRA) curve for the treatment-based outcomes. This study is registered with PROSPERO, number CRD42020158985.

RESULTS

Sixty-two RCTs (at least 73% of which were double blinded) that included a total of 6708 subjects and compared 6 categories of drugs and/or placebos were ultimately enrolled. All preventive interventions except lidocaine were more effective than placebo at the 4 time intervals. Lidocaine (OR: 0.35, 95% credible interval [CrI], 0.16-0.79) has a greater POST preventative intervention effect than the placebo at a time interval of only 2 to 3 hours after surgery. Relative to lidocaine, the risk of POST except 2 to 3 hours was lower for the following treatments: corticosteroids, ketamine, magnesium, NSAIDs, and Glycyrrhiza. The NMDA receptor antagonists studied here included ketamine and magnesium. Magnesium generally demonstrated greater benefit than ketamine at 24 hours postsurgery/extubation (OR: 0.41, 95% CrI, 0.18-0.92). Compared with ketamine, corticosteroids were associated with a reduced risk of POST during the 4 to 6 hours (OR: 0.40, 95% CrI, 0.19-0.83) and 24 hours (OR: 0.34, 95% CrI, 0.16-0.72) time intervals. During the 2 to 3 hours time interval, Glycyrrhiza (OR: 0.38, 95% CrI, 0.15-0.97) was more efficacious than magnesium.

CONCLUSIONS

Our analysis shows that, among the 6 topical medications studied, lidocaine is not optimal for topical use to prevent POST. Glycyrrhizin, corticosteroids, NSAIDs, and NMDA receptor antagonists (ketamine and magnesium) are associated with a reduced postoperative pharyngeal pain across the 4 postsurgical time intervals studied, all of which can be chosen according to the clinical experience of the anesthesiologists and the patient preferences and are recommended for the reduction of postoperative throat pain.

Comparison of Ambu AuraGain at low cuff pressure, Ambu AuraGain at high cuff pressure and i-gel in relation to incidence of postoperative upper airway complications

Background and Aims:

Postoperative upper airway complications are frequently encountered with the use of supraglottic airway devices (SADs). Cuff pressure is one of the risk factors for upper airway complications with SADs. Among SADs, i-gel has shown lesser incidence. The effect of different cuff pressures on the incidence of postoperative upper airway complications is not known with Ambu AuraGain and nor has Ambu AuraGain been compared with i-gel in this regard. So, we undertook this study.

Methods:

A total of 200 patients undergoing elective laparoscopic surgery were randomised into 3 groups based on the SAD used and intra-cuff pressure: i-gel (IG) (n = 66); Ambu AuraGain at 25 cmH₂O cuff pressure (AL) (n = 67); and Ambu AuraGain at 60 cmH₂O cuff pressure (AH) (n = 67). The oropharyngeal leak pressures (OLPs) were measured after insertion and generation of carboperitoneum. An observer who was blind to the intraoperative details assessed the patients for two postoperative days for sore throat, dysphagia, dysphonia, or any other upper airway complications.

Results:

The OLPs before and after carboperitoneum in the 3 groups were (IG-24.22 ± 7.87 and 28.31 ± 8.52, AL-24.40 ± 5.84 and 26.94 ± 5.93, AH-25.02 ± 5.02 and 28.91 ± 5.6) cmH₂O (P = 0.747 and P = 0.231). The overall incidence of postoperative sore throat among the 3 groups was: IG-5.7%, AL-14.9%, and AH-17.9%; P = 0.135. Dysphagia was seen only with Ambu AuraGain at high pressure in 4 patients (5.97%) (P = 0.017).

Conclusion:

Limiting cuff pressure in Ambu AuraGain to 25, as against 60 cmH₂O, does not affect the OLP but has the potential of reducing the incidence of dysphagia.

Efficacy of perioperative intravenous dexmedetomidine administration for the prevention of postoperative sore throat: a meta-analysis

Objective

Postoperative sore throat (POST) is an undesirable intubation-related complication after surgery. Several studies have investigated the efficacy of perioperative intravenous dexmedetomidine administration for the prevention of POST, but the results have been inconsistent. We aimed to summarize all existing evidence and draw a more precise conclusion to guide future clinical work.

Methods

PubMed, Cochrane Library, EMBASE and China National Knowledge Infrastructure databases were comprehensively searched for all randomized controlled trials published before 1 February 2021 that investigated the efficacy of dexmedetomidine for the prevention of POST.

Results

Nine studies involving 400 patients were included in our meta-analysis. Compared with the control groups (i.e., saline and anesthetic drugs), perioperative intravenous use of dexmedetomidine significantly reduced the incidence of POST [risk ratio (RR): 0.56; 95% confidence interval (CI): 0.40–0.77; I² = 0%) and coughing on the tube during extubation (RR: 0.58; 95% CI: 0.41–0.82; I² = 0%). Additionally, patients in the dexmedetomidine group were more likely to develop bradycardia (RR: 2.46; 95% CI: 1.28–4.71; I² = 0%) and hypotension (RR: 3.26; 95% CI: 1.14–9.33; I² = 0%) during the administration of dexmedetomidine than those in the control group.

Conclusion

Perioperative intravenous administration of dexmedetomidine has a positive effect on the prevention of POST.

Endotracheal Tube Intracuff Pressure Changes in Patients Transported by a Helicopter Emergency Medical Service: A Prospective Observational Study

OBJECTIVE

The pressure within an endotracheal tube cuff is of particular importance in helicopter emergency medical services (HEMS) transport because the unpressurized cabin is subjected to decreases in atmospheric pressure. This can cause the cuff to overinflate and may be associated with clinical complications. We sought to evaluate endotracheal tube cuff pressure changes among intubated patients during HEMS transport.

METHODS

A prospective observational study was performed including adult patients who were intubated and transported by helicopter between April 2017 and October 2018. Cuff pressures were measured before, during, and after HEMS transport with a commercial manometer.

RESULTS

A total of 208 patients were included. The median maximum flight altitude was 3,000 (interquartile range [IQR], 2,000-5,000) ft. The median initial cuff pressure before takeoff was 35 (IQR, 24-50) cm H₂O, which increased to 50 (IQR, 35-70) cm H₂O at maximum altitude. A total of 169 (81.3%) patients had a cuff pressure > 30 cm H₂O at maximum altitude. There was a moderate correlation between altitude and cuff pressure (r = 0.532, P < .001).

CONCLUSIONS

Cuff pressure increased during HEMS transport, demonstrating the need for routine cuff pressure monitoring during flight. Further research is required to determine if exposure to transient increases in cuff pressure for short durations is clinically significant.

Uvular Necrosis After Shoulder Surgery: A Report of Three Cases

Uvular necrosis is a rare postoperative complication that can manifest from endotracheal tube intubation or laryngeal mask airway placement resulting in compression and restriction of blood flow to the uvula. This report describes three patients who underwent outpatient shoulder surgery under general anesthesia and were subsequently diagnosed with uvular necrosis. Their symptoms included persistent sore throat, dysphagia, odynophagia, and foreign body sensation, with swelling and white exudate on the uvular tip. All three patients were treated conservatively and had complete symptom resolution. While symptoms from uvular necrosis typically self-resolve within two weeks, it is important to recognize the condition and risk factors because patients may benefit from reassurance and conservative treatment.

Patient's experiences of endotracheal tubes and suction following cardiac surgery

BACKGROUND

There is a growing body of evidence addressing the patient experience of intensive care, including patient reports that the presence of an endotracheal tube is bothersome and distressing, and that endotracheal suction is moderately to extremely painful. Yet there remains little information about the patient experience of the endotracheal tube and suction in those patients receiving planned short-term mechanical ventilation.

AIMS AND OBJECTIVES

This study aimed to describe the patient experience of the endotracheal tube and suction, following mechanical ventilation in post-operative cardiac surgical patients.

DESIGN

This qualitative study used inductive thematic analysis. Participants having planned cardiac surgery, anticipated to receive less than 12-hours mechanical ventilation, were approached pre-operatively and written consent provided.

METHODS

Ten participants were recruited using purposive sampling. Semi-structured interviews were conducted between days four and six post-operatively. One researcher interviewed all participants; two researchers independently read, coded, and agreed themes.

FINDINGS

None of the participants recalled endotracheal suction, while half had no recollection of the endotracheal tube. Three themes were identified; the experience of the endotracheal tube and extubation, the experience of emerging from sedation, and participants concerns about the future. The presence of the endotracheal tube was described as bothersome, whilst breathing through the tube and extubation were described as 'weird' and 'strange' but not painful.

CONCLUSIONS

Knowledge of the patient experience can help inform nursing practice by improving pre and post-operative care planning.

RELEVANCE TO CLINICAL PRACTICE

This study adds to the body of knowledge about the patient experience of the endotracheal tube and extubation.

TRIAL REGISTRATION

Prospective registration with the Australian New Zealand Clinical Trials Registry. www.anzctr.org.au (ACTRN12616001515482).

Influence of two-handed jaw thrust during tracheal intubation on postoperative sore throat: a prospective randomised study

Objective

General anaesthesia with tracheal intubation results in sore throat. We evaluated the influence of the two-handed jaw thrust on postoperative sore throat in patients who require tracheal intubation.

Methods

In this prospective, double-blind, single-centre, parallel-arm, and randomised trial, 92 patients who were scheduled for general anaesthesia for total hip arthroplasty were allocated to one of two groups. In the jaw thrust group (n = 46), the two-handed jaw thrust manoeuvre was applied at intubation. In the control group (n = 46), conventional intubation with sham jaw thrust was performed. Incidences of airway morbidities including sore throat, hoarseness, and cough at 2, 4, and 24 hours postoperatively were compared.

Results

During the postoperative 24 hours, the incidence of sore throat (8 [17%] vs. 20 [44%]) and hoarseness were lower in the jaw thrust group (8 [17%] vs. 18 [39%]) compared with the control group. The incidence of cough during the postoperative 24 hours was similar between the groups.

Conclusions

The jaw thrust manoeuvre significantly reduced sore throat and hoarseness in patients after general anaesthesia using tracheal intubation.

Clinical trial registration: NCT 03568279.