• Users Online: 146
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 9  |  Issue : 1  |  Page : 8-12

A comparative study of the effect of dexamethasone versus its use with clonidine on postoperative sore throat and hoarseness of voice


Department of Anaesthesia and Surgical Intensive Care, Faculty of Medicine, Alexandria University, Egypt

Date of Submission27-Jan-2020
Date of Decision20-Apr-2020
Date of Acceptance19-Jul-2020
Date of Web Publication13-May-2022

Correspondence Address:
MBBS & Master Degree Hamed M.D Khattab
Anaethesia and Surgical ICU, Alexandria University, 103 BLD 102, RD 22, Juffair 324 Kingdom of Bahrain, Postal Code 324
Egypt
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/roaic.roaic_9_20

Rights and Permissions
  Abstract 


Regardless of some preventive measures, postoperative sore throat (POST) and hoarseness of voice are most undesirable and most frequent complication in the post-operative period [1,2]. Postoperatively it seems reasonable that most of the signs and symptoms are the result of mucosal injury which leads to inflammation caused by the process of air way instrumentation, also its postulated etiology has been associated with mucosal dehydration or edema, tracheal ischemia secondary to the pressure of endotracheal tube cuffs, aggressive oropharyngeal suctioning and mucosal erosion from friction between delicate tissues and the endotracheal tube (ETT) [4,5]. Aim, the primary outcome was to compare between the effects of Dexamethasone alone versus its use with Clonidine on post-operative sore throat. The secondary outcome was to compare between the effects of Dexamethasone alone versus its use with Clonidine on post-operative hoarseness of voice. Method, this prospective controlled randomized double- blind study was carried on 126 patients divided into two groups the Dexa group 63 and Dexaclonidine group 63. Randomization were done by using closed envelop technique opened immediately before induction by an anaesthetist who was unaware of the study protocol and responsible for preparing the study drugs. Patient in Dexaclonidine group received oral 150 microgram Clonidine tablet one hour before induction, whereas patients in the Dexa group received placebo which is multivitamin tablet with the same shape and size of Clonidine. Both Clonidine and placebo were covered with nontransparent paper. Patients in both groups were received 5 ml of normal saline containing Dexamethasone (8 mg) iv at 30 min before anaesthetic induction. Sedation with midazolam was given (0.05 mg/kg) IV 15 minutes before surgery for the two groups. On arrival to operating room patients were cannulated and monitored with electrocardiography, non-invasive blood pressure, pulse oximetry and capnography. Anaesthesia was induced with intravenous propofol (2 mg/kg) and fentanyl (1–1.5 micro g/kg) after approximately 5 min of preoxygenation and face mask ventilation. Rocuronium (0.6–0.8 mg/ kg) was administered to facilitate endotracheal intubation after using of nerve stimulator (train of four) to ensure complete muscle relaxation before intubation, an endotracheal tube were inserted (ETTs) after Cormack-Lehane scoring (13) of internal diameter 7.0 and 7.5 were used for females and males, respectively by Direct laryngoscopy with either a Macintosh blade size 3 or 4. The ETTs were inserted so that the vocal cords were located between the two indicator marks on the proximal part of the tube shaft. Intubations were confirmed by capnography and chest auscultation for equality of air entry on both sides. None of the patients received topical lidocaine or lidocaine jelly during the intubation procedure. The lungs were ventilated with 50% air 50% oxygen; ventilation was adjusted to maintain an end tidal carbon dioxide of 35–45 mmHg. Anaesthesia was maintained with isoflurane and intermittent bolus dose of rocuronium. Isoflurane concentration was adjusted to minimal alveolar concentration (MAC) 1–1,5% according to haemodynamics. After the end of surgery, residual neuromuscular relaxation was reversed by Neostigmine (0.03_0.07 mg/ kg) and Atropine (0,02–0,1 mg/kg). Oropharyngeal suction was gently performed under direct vision by soft suction catheter with sideway port to avoid trauma to the tissues before extubation, one end of the catheter was attached to an aspirator or collection canister and the unattached end was placed directly into a tube to extract secretions safely without injury to the mucous membranes. Conclusion From this study including that addition of clonidine to dexamethasone was more superior in reducing POST & hoarseness of voice than dexamethasone alone, resulted in more haemodynamic stability in both intra operative and early post-operative period. Result From this study, there was statistically significant difference between the two studied groups regarding the sore throat and hoarseness of voice incidence and grade (P value < 0.05). so, Addition of clonidine to dexamethasone was more superior in reducing POST & hoarseness of voice than dexamethasone alone.

Keywords: dexamethasone and clonidine, hoarseness of voice, post-operative sore throat (POST)


How to cite this article:
Mohamed MM, Mohamed R, Mohamed ML, Khattab HM. A comparative study of the effect of dexamethasone versus its use with clonidine on postoperative sore throat and hoarseness of voice. Res Opin Anesth Intensive Care 2022;9:8-12

How to cite this URL:
Mohamed MM, Mohamed R, Mohamed ML, Khattab HM. A comparative study of the effect of dexamethasone versus its use with clonidine on postoperative sore throat and hoarseness of voice. Res Opin Anesth Intensive Care [serial online] 2022 [cited 2022 Oct 6];9:8-12. Available from: http://www.roaic.eg.net/text.asp?2022/9/1/8/345214




  Introduction Top


Despite rapid advancement in anesthetic techniques, sore throat following endotracheal intubation is still a long-standing concern for anesthesiologists. The overall incidence of postoperative sore throat (POST) after general anesthesia with endotracheal intubation varies from 20 to 74%, and it was ranked as the second most common minor adverse event during recovery of general anesthesia [1],[2]. The etiology is multifactorial, including patient-related factors such as age [3], sex [4],[5],[6], and smoking [7], and intubation factors, including technique [8], duration [3], tube size [4], intracuff pressure [9],[10], cuff design [3], intraoperative tube movement [4], and suctioning [8].

POST may temporarily reduce the quality of life and increase patient dissatisfaction [1],[2],[3]. POST occurs not only after endotracheal intubation but after laryngeal mask airway as well. Careful insertion technique for both the tracheal tube and laryngeal mask is of importance for the prevention of airway trauma and POST. Prophylactic management for POST is recommended to increase the quality of postoperative care [5].

Several studies demonstrate that intravenous dexamethasone alone reduces the incidence and severity of sore throat at first and 24 h postoperatively [4],[8],[10],[11]. Dexamethasone is a potent glucocorticoid with minimal to no mineralocorticoid activity. It decreases the inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability; stabilizes cell and lysosomal membranes; increases surfactant synthesis; increases serum vitamin A concentration; inhibits prostaglandins and proinflammatory cytokines; suppresses lymphocyte proliferation through direct cytolysis; inhibits mitotic division, breaks down granulocyte aggregates, and improves pulmonary microcirculation; therefore, it has potent anti-inflammatory, analgesic, and anti-emetic effects [6],[7].

Clonidine is a central sympatholytic medication that acts via stimulation of alpha-2 adrenergic receptors, resulting in reduction of sympathetic outflow, causing decreased peripheral vascular resistance, heart rate, blood pressure, and renal vascular resistance, as it produces presynaptic and postjunctional alpha-2 adrenoreceptor analgesia by preventing pain signal transmission to brain. Clonidine is used for treatment of high blood pressure; anxiety disorder; alcohol, opioids, or smoking withdrawal syndrome; migraine and pain sensation. It is indicated for the short-term management of acute postoperative pain in both children and adults, and it also significantly reduces postoperative opioid requirements [9],[10],[12],[13]. However, its effects on the incidence of POST have not been fully investigated. Many hypotheses assume that a combination of clonidine and dexamethasone may reduce the incidence and severity of POST associated with endotracheal intubation compared with intravenous dexamethasone alone.


  Aim Top


The primary outcome is to compare between the effects of dexamethasone alone versus its use with clonidine on POST.

The secondary outcome is to compare between the effects of dexamethasone alone versus its use with clonidine on postoperative hoarseness.


  Patients and methods Top


Patients

After obtaining the local ethics committee’s approval, written informed consent was acquired from each patient. The current study was carried out in Alexandria University Hospital on 126 patients who underwent minor abdominal surgery. The sample size and the number of the study groups were approved to be sufficient by the Department of Medical Statistics of Medical Research Institute, Alexandria University.

Patients were randomly assigned into one of two equal groups: the dexamethasone group (D group=63) and dexamethasone plus clonidine group (DC group=63) using closed envelope technique:
  1. Group 1: patients in the D groups received 5 ml of normal saline containing dexamethasone (8 or 10 mg) at 30 min and placebo, which is a multivitamin tablet similar to the shape of clonidine at 1 h before anesthetic induction.
  2. Group 2: patients in the dexaclonidine group received 5 ml of normal saline containing dexamethasone (8 or 10 mg) at 30 min and clonidine (150 μg) tablet at 1 h before anesthetic induction. Both clonidine and placebo were covered with a nontransparent paper.


Inclusion criteria

Patients aged 18–50 years with American Society of Anesthesiologists physical status I or II [14] of either sex were included.

Exclusion criteria

The following were the exclusion criteria:
  1. Patients with a history of pre-existing sore throat and/or hoarseness.
  2. Anticipated difficult intubation.
  3. Mallampati grade more than 2.
  4. More than one attempt at intubation.
  5. Known allergies to dexamethasone and clonidine.
  6. Smoking.
  7. Upper respiratory tract infections.
  8. Patients who need nasogastric tube insertion.
  9. Operation which is prolonged to more than 2 h.



  Methods Top


Preoperative workup of all patients included the following:
  1. History taking.
  2. Complete physical examination.
  3. Airway assessments, including mouth opening, neck mobility, Mallampati score, and thyromental distance.
  4. Laboratory investigation:

  5. Complete blood picture.
  6. Prothrombin time and activity, activated partial thromboplastin time, and international normalized ratio.
  7. Serum urea and creatinine.
  8. Fasting blood sugar.
  9. ECG for patients above 40 years of age.


This prospective controlled randomized double-blind study was carried out on 126 patients divided into two groups: the D group (63 patients) and DC group (63 patients). Randomization was done by using the closed envelop technique. The envelopes were opened immediately before induction by an anesthetist who was unaware of the investigation protocol and responsible for preparing the study drugs.

Patients in dexaclonidine group received oral 150 μg of clonidine tablet 1 h before induction [12], whereas patients in the D group received placebo, which is a multivitamin tablet with the same shape and volume of clonidine. Both clonidine and placebo were covered with a nontransparent paper [11]. Patients in both groups received 5 ml of normal saline containing dexamethasone (10 mg) intravascular at 30 min before anesthetic induction. Sedation with midazolam was given (0.05 mg/kg) intravascular 30 min before surgery for the two groups.

On arrival to the operating room, patients were already cannulated and were monitored with ECG, noninvasive blood pressure, pulse oximetry, and capnography. Anesthesia was induced with intravenous propofol (2 mg/kg) and fentanil (1–1.5 μg/kg) after ∼5 min of preoxygenation and face mask ventilation. Rocuronium (0.6–0.8 mg/kg) was administered to facilitate endotracheal intubation after using of nerve stimulator to ensure complete muscle relaxation before intubation. An endotracheal tube (ETT) was inserted after Cormack–Lehane scoring [13] of internal diameter 7.0 and 7.5 2for females and males, respectively, by direct laryngoscopy with either a Macintosh blade size 3 or 4.

The ETT was inserted so that the vocal cords were located between the two indicator marks on the proximal part of the tube shaft. Intubation was confirmed by capnography and chest auscultation for equality of air entry on both sides. None of the patients received topical lidocaine or lidocaine jelly during the intubation procedure. The lungs were ventilated with 50% air 50% oxygen; ventilation was adjusted to maintain an end tidal carbon dioxide of 35–45 mmHg. Anesthesia was maintained with isoflurane and intermittent bolus dose of rocuronium. Isoflurane concentrations were adjusted to minimal alveolar concentration 1,5. After the end of surgery, residual neuromuscular relaxation was reversed by neostigmine (0.03–0.07 mg/kg) and atropine (0.02–0.1 mg/kg). Oropharyngeal suction was gently performed under direct vision with suction catheter to avoid trauma to the tissues before extubation. Suction catheter with sideway port was used to extract secretions, from the upper airway. One end of the catheter was attached to an aspirator or collection canister. The unattached end was placed directly into a trach tube to extract secretions safely without injury to the mucous membranes.

Extubation of ETT was performed as follows:
  1. Removal of adhesive tape while the patient is in deep anesthesia.
  2. After resumption of adequate spontaneous breathing and response to verbal commands.
  3. Gentle suction under direct vision before extubation.
  4. After complete deflation of the tube cuff during inspiration.
  5. Patient was extubated during next inspiration.


Measurements

The following measurements were carried out in both groups:
  1. Patient demographic data, including age, sex, BMI, and American Society of Anesthesiologists physical status, were recorded for all patients.
  2. Vital signs:
    1. Heart rate (beat/min).
    2. Mean arterial blood pressure (mm/Hg). Baseline reading was measured before induction of anesthesia, intraoperatively every 15 min till the end of surgery, postoperatively every 2 h for the first 6 postoperative hours, and then every 6 h till the end of 24 h.
  3. Clinical:


Airway scores included Mallampati and Cormack–Lehane scores. Mallampati grades were as follows: grade 1, complete view of the uvula; grade 2, absence of the tip of the uvula; grade 3, presence of the base of the uvula; and grade 4, complete absence of the uvula. Laryngoscopic view assessment using the Cormack and Lehane grade was noted by the investigator performing tracheal intubation. The time of intubation was measured as the duration between inserting the laryngoscope blade into the patient’s mouth and removal of laryngoscopic blade. The cuff of ETT was inflated with suitable volume of air using hand-held manometer adjusted at 20 mmHg to prevent an audible leak.

The following surgery-related characteristics were also recorded for all patients: surgery type, patient’s position during surgery, and anesthetic data such as duration of anesthesia, total rocuronium dose, total fentanil dose, cuff pressures at intubation and emergence, cough at emergence, and hoarseness at postanesthesia care unit (PACU) [13].

After extubation, patients was transferred to the PACU. The incidence of sore throat and hoarseness was scored by an independent observer. It was recorded either ‘yes’ or ‘no’ after the 30 min from arrival to the PACU. Sore throat was defined as pain at the pharynx. Questionnaire survey was asked about any source of pain to detect sore throat, such as ‘Do you have any pain after operation?’

Hoarseness was defined as a harsh or strained voice complained by the patients. If the observer observed the patient’s voice change, it was also scored as ‘yes.’ After the survey, the incidences of sore throat and hoarseness were assessed by an observer at 1, 6, 12, and 24 h postoperatively. Sore throat was checked at rest and while swallowing. It was graded on a four-point scale (0–3):

  • 0=no sore throat.
  • 1=mild sore throat (complaints of sore throat only on asking).
  • 2=moderate sore throat (complaints of sore throat on his/her own).
  • 3=severe sore throat (change in voice or hoarseness, associated with throat pain) [15].


  • Hoarseness was graded on a four-point scale (0–3):
    1. 0=no complaint of hoarseness.
    2. 1=minimal hoarseness (minimal change in quality of speech of which patient answers in the affirmative only when asked).
    3. 2=moderate hoarseness (moderate change in quality of speech of which the patient complains on his/her own).
    4. 3=severe hoarseness (gross change in the quality of voice perceived by the observer) [16].


    Postoperative resting surgical pain was assessed using a numerical rating scale of 10 points: 0: no pain, and 10: worst imaginable pain. At the same time, patients received 5 mg nalbuphine as analgesic for patients feeling pain more than grade 5.

    Other complication was also noted such as nausea, vomiting, drowsiness, shivering, headache, and postoperative pain scores after 24 h postoperatively.


      Ethics of research Top


    Research on human or human products

    Regarding prospective arm of the study, informed consent was taken from the patients. In case of incompetent patients, the informed consent was taken from the guardians.

    Regarding retrospective arm of the study, confidentiality of records was considered.

    DNA/genomic material: informed consent for DNA/genomic test and for research was taken from the patients. No further test was carried out, except with further approval of the committee and the patients. If the samples were to be taken outside Egypt, the researchers were responsible for transportation and security approval.

    All drugs used in the research have been approved by the Egyptian Ministry of Health.

    Research on animal

    The animal species are appropriate for the test.

    After test, if animal will suffer, it will be euthanized and properly disposed.

    After operation, it will have a proper postoperative care.


      Results Top


    The results of this study have been tabulated and analyzed with the use of appropriate statistical methods and appropriate figures and diagrams.


      Discussion Top


    The results have been discussed in view of the achievement of the aim, their significance, and their comparison with previous related research studies.

    Financial support and sponsorship

    Nil.

    Conflicts of interest

    There are no conflicts of interest.



     
      References Top

    1.
    Lehmann M, Monte K, Barach p. Postoperative patient complaints: a prospective interview study of 12,276 patients. J Clin Anesth 2010; 22:13–21.  Back to cited text no. 1
        
    2.
    Arts MP, Rettig TC, Vries D. Maintaining endotracheal tube cuff pressure at 20 mmHg to prevent dysphagia after anterior cervical spine surgery; protocol of a double-blind randomised controlled trial. BMC Musculoskelet Disord 2013; 14:280–280.  Back to cited text no. 2
        
    3.
    El-Boghdadly K, Bailey CR, Wiles MD. Postoperative sore throat: a systematic review. Anaesthesia 2016; 71:706–717.  Back to cited text no. 3
        
    4.
    Hu B, Bao R, Wang X. The size of endotracheal tube and sore throat after surgery: a systematic review and meta-analysis. PLoS ONE 2013; 8:e74467–e74467.  Back to cited text no. 4
        
    5.
    Orandi A, Orandi A, Najafi A. Post-intubation sore throat and menstruation cycles. Anesth Pain Med 2013; 3:243–249.  Back to cited text no. 5
        
    6.
    Christensen AM, Willemoes-Larsen H, Lundby L. Postoperative throat complaints after tracheal intubation. Br J Anaesth 1994; 73:786–787.  Back to cited text no. 6
        
    7.
    Biro P, Seifert B, Pasch T. Complaints of sore throat after tracheal intubation: a prospective evaluation. Eur J Anaesthesiol 2005; 22:307–311.  Back to cited text no. 7
        
    8.
    McHardy FE, Chung F. Postoperative sore throat: cause, prevention and treatment. Anaesthesia 1999; 54:444–453.  Back to cited text no. 8
        
    9.
    Combes X, Schauvliege F, Peyrouset O. Intracuff pressure and tracheal morbidity: influence of filling with saline during nitrous oxide anesthesia. Anesthesiology 2001; 95:1120–1124.  Back to cited text no. 9
        
    10.
    Seegobin RD, Van Hasselt GL. Endotracheal cuff pressure and tracheal mucosal blood flow: endoscopic study of effects of four large volume cuffs. Br Med J (Clin Res Ed) 1984; 288:965–968.  Back to cited text no. 10
        
    11.
    Higgins PP, Chung F, Mezei G. Postoperative sore throat after ambulatory surgery. Br J Anaesth 2002; 88:582–584.  Back to cited text no. 11
        
    12.
    Maruyama K, Yamada T, Hara K. Effect of clonidine premedication on postoperative sore throat and hoarseness after total intravenous anesthesia. J Anesth 2006; 20:327–330.  Back to cited text no. 12
        
    13.
    Cormack RS, Lehane J. Difficult tracheal intubation in obstetrics. Anaesthesia 1984; 39:1105–1111.  Back to cited text no. 13
        
    14.
    American Society of Anesthesiologists. ASA physical status classification system. 2014. Available at: https://www.asahq.org/resources/clinical-information/asa-physical-status-classification-system. [Accessed September 12, 2016].  Back to cited text no. 14
        
    15.
    Agarwal A, Nath SS, Goswami D, Gupta D, Dhiraaj S, Singh PK. An evaluation of the efficacy of aspirin and benzydamine hydrochloride gargle for attenuating postoperative sore throat: a prospective, randomized, single-blindstudy. Anesth, Analg. 2006;103:1001–1003.  Back to cited text no. 15
        
    16.
    Sultan P, Carvalho B, Rose BO. Endotracheal tube cuff pressure monitoring: a review of the evidence. J Perioper Pract 2011; 21:379–386.  Back to cited text no. 16
        




     

    Top
     
     
      Search
     
    Similar in PUBMED
       Search Pubmed for
       Search in Google Scholar for
     Related articles
    Access Statistics
    Email Alert *
    Add to My List *
    * Registration required (free)

     
      In this article
    Abstract
    Introduction
    Aim
    Patients and methods
    Methods
    Ethics of research
    Results
    Discussion
    References

     Article Access Statistics
        Viewed296    
        Printed26    
        Emailed0    
        PDF Downloaded46    
        Comments [Add]    

    Recommend this journal


    [TAG2]
    [TAG3]
    [TAG4]