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Background: Whenever endotracheal intubation is carried out during surgeries, patients commonly complain of sore throat after surgery. For its prevention, dexamethasone has been studied and found useful. However, there are limited data on comparing the efficacy of different routes of prophylactic dexamethasone for sore throat postoperatively after lumbar spine surgery in the prone position.
Objective: The objective of the study was to compare the efficacy of nebulized dexamethasone with intravenous dexamethasone for the prevention of postoperative sore throat after lumbar spine surgery in the prone position.
Materials and Methods: Hospital based randomized comparative study carried out among 70 patients of the American Society of Anesthesiologists (ASA) 1 and 2 aged between 20 and 60 years. They were randomly allocated into one of the two groups. Group N received 8 mg dexamethasone in 2 ml of normal saline as nebulization 30 min before induction. Group I received 8 mg dexamethasone intravenously 5 min before induction. Postoperatively, looked for symptoms of sore throat and hoarseness of voice at 2, 6, 12, and 24 h.
Results: Both groups were comparable for age, sex, ASA grades, Mallampati grades, duration of surgery, and size of the endotracheal tube. At 2, 6, 12, and 24 h after surgery, the incidence of sore throat was higher in Group I compared to Group N. These differences at each time interval were statistically significant (P < 0.05). At 6 h, the incidence in Group I patients was 65.7% compared to Group N patients (42.9%) (P < 0.05). At 12 and 24 h, the incidence of sore throat in Group I patients (60% and 37.1%, respectively) compared to Group N patients (28.6% and 17.1%, respectively) (P < 0.05).
Conclusion: Eight milligram of dexamethasone in 2 ml of normal saline as nebulization 30 min before induction was found to be more effective in reducing the incidence of sore throat compared to 8 mg dexamethasone intravenously 5 min before induction.
Keywords: Dexamethasone, incidence, induction, nebulization, sore throat
How to cite this URL:
Ramamurthy S, Bettaswamy G. A comparative study of prophylactic nebulized dexamethasone versus intravenous dexamethasone for prevention of postoperative sore throat in prone-position surgeries. MRIMS J Health Sci [Epub ahead of print] [cited 2023 May 29]. Available from: http://www.mrimsjournal.com/preprintarticle.asp?id=372137 |
| Introduction | |  |
Postoperative sore throat (POST) is a common complication after general anesthesia by endotracheal intubation. It is associated with morbidity. Patients are also not satisfied. The incidence of POST has been reported to vary from 14% to 90% and that of hoarseness of voice varies from 4% to 43% even under optimal intubating conditions.[1],[2] There are several factors that have been shown to contribute to POST such as patient-related factors, type of anesthesia, and type of surgery.[3],[4]
For the reduction of POST, as well as hoarseness of voice, many modalities have been tried and published. They include both drugs as well as nonpharmacological modalities. In pharmacological methods, various drugs have been studied and have found to be effective such as dexamethasone, ketamine, magnesium sulfate, and lignocaine.[3],[4]
Among all these agents, dexamethasone is commonly used. It is a glucocorticoid. It has not only anti-inflammatory properties but also reduces pain and prevents vomiting.[5],[6] During endotracheal intubation, there is an injury to the tissues which is modified by dexamethasone. This is how it reduces the incidence of POST as well as hoarseness of voice.[7],[8],[9],[10]
When the surgeries are carried out in prone positions under general anesthesia, there is more damage due to endotracheal intubation. Thus, there is more incidence of POST among those who undergo surgeries in the prone position.[11],[12],[13] Comparison of the efficacy of different routes of prophylactic dexamethasone for POST after lumbar spine surgery in prone position is less studied and is the main objective of this study.
| Materials and Methods | | |
This was a hospital based open label randomized comparative study carried out from August 2022 to October 2022 at the Department of Anesthesiology, Adichunchanagiri Institute of Medical Sciences, Karnataka.
Institutional ethics committee approval was taken before the study was initiated. Written informed consent was taken from all the patients, and after their consent, only the patients were registered. Seventy patients of the American Society of Anesthesiologists (ASA) 1 and 2 aged 20–60 years posted for lumbar spine surgery in prone position under general anesthesia by endotracheal intubation were selected. Patients with recent upper respiratory tract infection, more than two attempts for laryngoscopy or intubation, use of airway adjuncts such as stylet or bougie, and anticipated difficult intubation were excluded from the study.
All patients underwent preanesthetic checkup by the principal investigator. Random allocation software was used to randomize the patients into two groups.
- Group N received 8 mg of dexamethasone in 2 ml of normal saline as nebulization 30 min before induction
- Group I received 8 mg dexamethasone intravenously before induction.
The night preceding the surgery, alprazolam was given in the dose of 0.5 mg orally. On the operative day, in the preoperative room, pulse oximeter and blood pressure were attached to the patients. The intravenous line was secured. Group N received 8 mg of dexamethasone in 2 ml of normal saline as nebulization 30 min before induction. Group I received 8 mg of dexamethasone intravenously before induction. Fentanyl was used in the dose of 2 μg/kg and propofol was used in the dose of 2 mg/kg along with vecuronium in the dose of 0.1 mg/kg for the induction of the anesthesia. With a gap of 5 min, intubation was done by the principal investigator. Appropriate size McIntosh blade was used. Single-use polyvinyl chloride portex tube was used for intubation. It had a large volume low-pressure cuff. The size for males was 8, 8.5 mm and the size for females was 7, 7.5 mm. Capnography was used to confirm the placement of the endotracheal tube. Anesthesia was maintained with appropriate guidelines. Oral suctioning was done gently after surgery. Glycopyrrolate and neostigmine were used in appropriate doses for reversal. Extubation was done when there was adequate ventilation and also when the patient followed the commands given verbally. For analgesia after surgery, an injection of tramadol was given intravenously as 50 mg.
As soon as the surgery was over, the patients were monitored for the presence of POST and hoarseness of voice at 2, 6, 12, and 24 h. The anesthesiologist who assessed the patients for these parameters was not aware about the route of administration of dexamethasone. Grading of sore throat was such as zero for no sore throat, one for mild, two for moderate, and three for severe sore throat. Mild means the patient complained only when he was asked about it. When he complained on his own, it was moderate. When the voice changed or hoarseness was there, it was a severe type.
The data were entered in the SPSS software version 22. The Chi-square test was used to compare proportions in the two groups. Student's t-test was used to compare mean values in the two groups. Statistical significance was considered when the P value was < 0.05.
| Results | | |
Both groups were comparable in terms of age and sex. The overall majority of the study subjects belonged to the age group of 41–50 years. Males and females were almost equal [Table 1].
While considering ASA and Mallampati grades, the proportion of patients in both groups was found to be similarly distributed (P > 0.05) [Table 2]. | Table 2: Comparison of the American Society of Anesthesiologists and Mallampati grade grades in two groups
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Patients from both groups underwent surgery for almost similar lengths of time. The average size of the endotracheal tube required for patients in both groups was almost similar (P > 0.05) [Table 3]. | Table 3: Comparison of duration of surgery and size of endotracheal tube in two groups
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At two hours after surgery, the incidence of sore throat was 74.3% in Group I patients compared to 48.6% in Group N which was found to be statistically significant (P < 0.05). Similarly, at 6 h, also the incidence of sore throat was significantly more in Group I patients (65.7%) compared to Group N patients (42.9%) (P < 0.05). At 12 and 24 h, also the incidence of sore throat was significantly more in Group I patients (60% and 37.1%, respectively) compared to Group N patients (28.6% and 17.1%, respectively), and these differences were also statistically significant (P < 0.05) [Table 4]. | Table 4: Comparison of sore throat in two groups at different time intervals after surgery
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A statistical test could not be applied in [Table 5] as many cells have zero values. Overall, at 2 and 6 h after surgery, the incidence of hoarseness of voice was only 2.9% each which was seen in only one patient of Group I which also disappeared at 12 h. There were no cases of hoarseness of voice in Group N at any point in time [Table 5].
| Discussion | | |
The incidence of POST is not constant. It varies from place to place as it depends on many factors. It may be due to some trauma to the oropharynx. It can also be due to injury to the base of the tongue or may be due to trauma to the posterior pharyngeal wall. Some patients may develop an allergy to the device used which can lead to inflammation.[14]
The factors such as gender, patient's age, and habit of smoking can also contribute to POST. It also depends on the type of operation, for how long the surgery was done, and what is the position of the patient while the surgery was being done. For example, in the prone position, it is more. The factors related to anesthesia are for how long the anesthesia was required, size of the tube, what is the technique of intubation, pressure of the cuff, movement of the tube during surgery, and emergency requirement of the suction.[15]
In the present study, both groups were comparable in terms of age and sex. The overall majority of the study subjects belonged to the age group of 41–50 years. Males and females were almost equal. While considering ASA and Mallampati grades, the proportion of patients in both groups was found to be similarly distributed (P > 0.05). Patients from both groups underwent surgery for almost similar length of time. The average size of the endotracheal tube required for patients in both groups was almost similar (P > 0.05). At 5 h after surgery, the incidence of sore throat was 74.3% in Group I patients compared to 48.6% in Group N which was found to be statistically significant (P < 0.05). Similarly, at 6 h, also the incidence of sore throat was significantly more in Group I patients (65.7%) compared to Group N patients (42.9%) (P < 0.05). At 12 and 24 h, also the incidence of sore throat was significantly more in Group I patients (60% and 37.1%, respectively) compared to Group N patients (28.6% and 17.1%, respectively), and these differences were also statistically significant (P < 0.05). A statistical test could not be applied in [Table 5] as many cells have zero values. Overall, at 2 and 6 h after surgery, the incidence of hoarseness of voice was only 2.9% each which was seen in only one patient of Group I which also disappeared at 12 h. There were no cases of hoarseness of voice in Group N at any point in time.
Bagchi et al.[10] found that the incidence of sore throat in the dexamethasone group was 18.8% only compared to the control group (48.9%) 1 h after extubation. This difference was found to be statistically significant. They concluded that intravenous dexamethasone is effective in reducing the incidence of sore throat after surgery.
Lee et al.[16] also observed that the incidence of sore throat in the intravenous dexamethasone group was significantly lower compared to the normal saline group at 1, 6, and 24 h after extubation. Similar results were observed for hoarseness. The incidence of cough was similar in the two groups. They thus concluded that intravenous dexamethasone was effective in reducing the incidence of POST and hoarseness of voice after surgery.
Ashwini et al.[17] compared dexamethasone in the dose of 8 mg in 3 ml saline nebulization with another group who were given magnesium sulfate 50% W/V 2 ml in 3 ml saline nebulization. They found that the incidence of POST was significantly lower in the dexamethasone group at different time intervals after surgery.
Jiang et al.[18] carried out a systematic review and meta-analysis to study the effect of dexamethasone in reducing the POST. They included 14 randomized controlled trials having 1837 patients. They found that the incidence of POST, postoperative nausea and vomiting (PONV), and hoarseness was significantly lesser in the dexamethasone group compared to the control group. They recommended the use of >0.2 mg/kg of dexamethasone given intravenously to patients undergoing surgeries with endotracheal intubation for reducing the incidence of POST, PONV, and hoarseness.
Mostafa et al.[19] compared three groups with 36 patients in each group. One group was given the magnesium sulfate in the dose of 40 mg/kg. The second group was given the ketamine in the dose of 1 mg/kg. The third group was given dexamethasone in the dose of 0.16 mg. They found that the incidence of POST was significantly lowest in the ketamine group at 4 h after surgery compared to the other two groups. They thus concluded that ketamine can be preferred compared to the other two drugs to reduce the intensity of POST as well as it will take care of adverse effects.
Kuriyama and Maeda et al.[20] carried out a systematic review and meta-analysis having a total of 1849 patients. They observed from these 15 randomized controlled trials that intravenous dexamethasone was effective in reducing the incidence of POST as well as the severity. Furthermore, the patients did not experience any serious side effects.
Limitation of our study was that we did not use a cuff pressure monitor to monitor the endotracheal tube cuff pressure intraoperatively and intermittently released the cuff pressure intraoperatively by manually feeling the cuff. There was no control group, so we could not compare the overall decrease in the incidence of POST and hoarseness of voice. The scale used to assess POST was a subjective scale and this may be associated with bias.
| Conclusion | | |
Eight milligram of dexamethasone in 2 ml of normal saline as nebulization 30 min before induction was found to be more effective in reducing the incidence of sore throat compared to 8 mg dexamethasone intravenously 5 min before induction. Therefore, we recommend using 8 mg of dexamethasone in 2 ml of normal saline as nebulization 30 min before induction to prevent the incidence of sore throat in patients undergoing lumbar spine surgery in prone position.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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Correspondence Address:
Guruprasad Bettaswamy,
Department of Neurosurgery, Adichunchanagiri Institute of Medical Sciences, B. G. Nagara, Karnataka
India
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/mjhs.mjhs_164_22
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5] |
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