Lidocaine versus dexamethasone for reduction of sore throat after general anesthesia: a comparative study

Mohammed N Mohammed; Ali El Said Rashad

doi:10.4103/roaic.roaic_74_21

ORIGINAL ARTICLE

Year : 2022 | Volume : 9 | Issue : 4 | Page : 297-301

Lidocaine versus dexamethasone for reduction of sore throat after general anesthesia: a comparative study

Mohammed N Mohammed, Ali El Said Rashad
Department of Anesthesia and Surgical ICU, Mansoura University, Mansoura, Egypt

Date of Submission	07-Nov-2021
Date of Acceptance	07-Mar-2021
Date of Web Publication	29-Dec-2022

Correspondence Address:
MD Mohammed N Mohammed
Department of Anaesthesia and Surgical Intensive Care, Faculty of Medicine, mansoura, 35511
Egypt

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/roaic.roaic_74_21

Abstract

Background Postoperative sore throat (POST) is commonly reported by patients after endotracheal intubation. This study was conducted to compare the efficacy of intravenous lidocaine and dexamethasone in the prevention of such problem.
Patients and methods We included a total of 394 cases who were randomly divided using the closed-envelope method into two groups: group D that included 197 cases who received intravenous dexamethasone (8 mg), and group L that included the remaining 197 cases who received intravenous lidocaine (1.5 mg/kg). Both the incidence and risk factors for POST were assessed.
Results Sore throat was reported by 115 (58.4%) cases in group L, whereas it was reported by 82 (41.6%) cases of cases in the other group. There was a marked reduction of sore-throat sensation in group D (P<0.001). Logistic regression revealed that the presence of blood on suction was a significant risk factor for developing sore throat after intubation.
Conclusion Intravenous administration of dexamethasone appears to be more promising than lidocaine in decreasing the incidence of POST.

Keywords: dexamethasone, lidocaine, postoperative sore throat

How to cite this article:
Mohammed MN, El Said Rashad A. Lidocaine versus dexamethasone for reduction of sore throat after general anesthesia: a comparative study. Res Opin Anesth Intensive Care 2022;9:297-301

How to cite this URL:
Mohammed MN, El Said Rashad A. Lidocaine versus dexamethasone for reduction of sore throat after general anesthesia: a comparative study. Res Opin Anesth Intensive Care [serial online] 2022 [cited 2023 Mar 26];9:297-301. Available from: http://www.roaic.eg.net/text.asp?2022/9/4/297/365801

Introduction

Sore throat is one of the most common undesirable problems that are encountered after endotracheal intubation (incidence 30–70%) [1].

Multiple mechanisms have been supposed for the pathogenesis of this problem, including airway inflammation secondary to pressure by the tube cuff, mucosal dehydration, and trauma during intubation [2],[3].

Multiple treatment options have been used to prevent the occurrence of this problem, including application of smaller endotracheal tube, low cuff pressure, aspirin, magnesium lozenges, steroids, and stellate ganglion blockade [4]. Previous studies have reported that intravenous administration of either dexamethasone or lidocaine in preventing that problem [5]-[7].

The administration of either intravenous dexamethasone or lidocaine has been generally accepted as it is easily available, simple, effective, and practicable in the operative theater [4].

This study was conducted to compare the efficacy of intravenous lidocaine and dexamethasone in the prevention of such problem.

Patients and methods

This is a prospective randomized study that was conducted at Mansoura University Hospitals during the period between March 2021 and September 2021 for cases who underwent endotracheal intubation for different surgical procedures.

This study included a total of 394 cases who were randomly divided using the closed-envelope method into two groups: group D that included 197 cases who received intravenous dexamethasone (8 mg), and group L that included the remaining 197 cases who received intravenous lidocaine 1.5 mg/kg.

We included cases whose age was between 18 and 60 years, having American Society of Anesthesiologists (ASA) I or II, requiring general anesthesia, from both sexes. Conversely, cases with preexisting sore throat, ASA more than II, Mallampati grade more than 2, current smoking, current respiratory-tract infections, pregnancy, obesity, receiving steroids preoperatively, or having contraindications for medications of the study were excluded.

An informed written consent was obtained from all cases. On arrival to the operation theater, patients were monitored through ECG, noninvasive pulse oximetry, and noninvasive blood-pressure measurement. Intravenous line was established. Both of the tested drugs were administered 5 min prior to induction of anesthesia.

Anesthesia was induced using propofol (0.5–2 mg/kg), fentanyl (1–2 μg/kg), as well as atracurium (0.05 mg/kg). We preferred to use an endotracheal tube with a high-volume/low-pressure cuff (7-mm internal diameter for females and 7.5 for males). The same anesthesiologist performed laryngoscopy in both groups via standard size-3 Macintosh metal blades.

The cuff was inflated to a pressure of 20 mmHg measured by a manometer. We did not use a bite block or oral airway in any of the included patients. After induction, anesthesia was maintained via sevoflurane (1.0–2.5 vol% end-tidal concentration). Normocapnia was maintained.

Neostigmine (0.04% mg/kg) and atropine (0.2 mg/kg) were used for the reversal of neuromuscular blockade.

Tracheal extubation was immediately performed after suctioning of the oropharyngeal fluid content by a soft rubber catheter to minimize tissue injury. Following extubation, all cases were transferred to the recovery room. The incidence of postoperative sore throat (POST) was our primary outcome, whereas the secondary outcome was to assess the risk factors for development of such problem.

Sample-size calculation

Sample size was calculated using Power Analysis and Sample Size software program (PASS Statistics for Windows, Version 15.0.5, NCSS, LLC Kaysville, Utah, USA.), version 15.0.5 using the results published by Subedi et al. [1] where the incidence of postintubation sore throat in the first 24 h was the primary outcome. Patients were randomly classified into two groups: lidocaine group and control group. The null hypothesis was considered as absence of reduction in the incidence of postintubation sore throat in the first 24 h in the lidocaine group. According to Subedi and colleagues, the incidence of postintubation sore throat was 43% in lidocaine group and 56% in control group. A sample size of 197 patients was needed in each group to achieve 80% power in the proposed study.

Statistical analysis

IBM’s SPSS statistics (version 25, 2017) was used for statistical analysis of the collected data. Quantitative variables were expressed as mean and SD, while categorical variables were expressed as frequency and percentage. Independent-sample t test and Mann–Whitney test were used for intergroup (between patients) comparison of parametric and nonparametric continuous data with no follow-up readings, respectively. Fisher exact and χ² tests were used for intergroup comparison of nominal data using the crosstabs function. A binary logistic regression model was conducted to determine the effects of the different factors on the risk of developing sore throat (R2).

Results

The mean age of the included cases was 35.27 and 34.42 years in groups D and L, respectively. Males represented 55.3 and 57.4% of cases in both groups, respectively, whereas the remaining cases were females. BMI had mean values of 30.8 and 31.00 kg/m² in the study groups, respectively. Most of the included cases had ASA score I (85.3 and 84.8% of cases respectively), while the remaining cases had ASA-II score. Regarding Mallampati score, 81.7 and 78.7% of cases in both groups had a score of I, while the remaining cases had score II. Neither of the previously discussed variables were significantly different between the two groups. [Table 1] illustrates these data.

Table 1 Demographic data, American Society of Anesthesiologists, and Mallampati classification

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The duration needed for intubation, and the duration of anesthesia did not significantly differ between the two groups (P>0.05). Also, external pressure was applied in 22.8 and 23.4% of cases in both groups, respectively (P=0.905), whereas blood was identified on suction in 4.1 and 3.6% of cases in both groups, respectively (P=0.792). [Table 2] illustrates these data.

Table 2 Time need to intubate, duration of anesthesia, application of external pressure for intubation, and blood on suction, in the studied groups

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Sore throat was reported by 115 (58.4%) cases in group L, whereas it was reported by 82 (41.6%) cases of cases in the other group. There was a marked reduction of sore-throat sensation in group D (P<0.001). [Table 3] illustrates these data.

Table 3 The incidence of postoperative sore throat in the study groups

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Logistic regression revealed that the presence of blood on suction and application of lidocaine were significant risk factors for developing sore throat after intubation. [Table 4] illustrates these data.

Table 4 Univariable logistic regression for the incidence of postoperative sore throat

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Discussion

This study was conducted at Mansoura University Hospitals aiming to compare the efficacy of intravenous lidocaine and dexamethasone in the prevention of POST. We included a total of 394 cases who were randomly divided into two groups: group D (197 cases who received intravenous dexamethasone), and group L (197 cases who received intravenous lidocaine).

Both groups showed no significant difference regarding patient characteristics. Also, the two groups were comparable regarding the time needed to intubate, duration of anesthesia, application of external pressure for intubation, and blood detection on suction (P>0.05).

To the best of our knowledge, there is a paucity of studies comparing the intravenous administration of dexamethasone versus lidocaine in the prevention of such problem.

Steroids are well known for their anti-inflammatory properties. These properties include inhibition of leukocyte migration and cytokine release at the site of inflammation. In addition, fibroblast proliferation is also inhibited [8],[9]. Moreover, dexamethasone moderates the inflammatory process via inhibition of arachidonic acid metabolism, leading to a decrease in leukotriene-B4 and inhibition of interleukin-2 [10].

Systemic dexamethasone was extensively studied to decrease the impact of this problem, and two meta-analyses have confirmed that intravenous dexamethasone significantly decreases the incidence of POST during the first 24 h [11],[12].

Lidocaine is the first local anesthetic of the aminoamide group, it is known to have analgesic and anti-inflammatory actions, and it has been commonly used for suppression of airway reflexes, reduction of bronchial hyperreactivity, and attenuation of laryngeal stress response from intubation [13].

Additionally, administration of intravenous lidocaine before intubation or at the end of surgery was proved to decrease the incidence of POST and cough [14],[15]. Nevertheless, the exact mechanism is still not completely understood [4],[15].

Lidocaine may suppress the excitation of sensory C fibers present in the airway. Also, it may lead to a decrease in sensory neuropeptide release [16].

Our results showed that dexamethasone was effective more than lidocaine in decreasing the incidence of POST (41.6 vs. 58.4%; P=0.001), although the included cases did not differ in preoperative or operative characteristics.

Previous studies comparing the efficacy of steroid and lidocaine on POST reported conflicting results, as some reported the significant superiority of steroids [17],[18], whereas another study reported comparable findings between the two medications [19].

A recent study conducted by Subedi and colleagues divided the included patients into four groups: dexamethasone, lidocaine, combined dexamethasone and lidocaine, and placebo groups. The incidence of POST was 36, 44, 25, and 56% in the four groups, respectively (P=0.02). Margin analysis revealed that the magnitude of sore throat showed a significant decrease with dexamethasone (whatever alone or combined with lidocaine), regardless of lidocaine use [1].

Another study has reported the superiority of dexamethasone over lidocaine in the prevention of POST, hoarseness of voice, and cough. Nevertheless, that study assessed the local application of these medications. During the early 24 h following surgery, the incidence of POST was 40, 100, and 100 for betamethasone, lidocaine, and control groups, respectively [18].

Hakim [17] also reported that beclomethasone inhaler (50 μg) led to a significant decrease in POST as it was reported by 10% of cases in the steroid group, compared with 55% of cases in the lidocaine group (55%).

Honarmand and Safavi [19] reported that pre-intubation application of beclomethasone inhaler was comparable to intravenous lidocaine in the reduction of POST and cough. Additionally, beclomethasone inhaler decreased both the incidence and severity of postoperative sputum.

Furthermore, a combination of the two drugs tested in the current study was proved to achieve significant improvement compared with dexamethasone alone in a previous study by Cho et al. [4]. This combination was not performed in the current study, and it should be considered in future studies to achieve more patient satisfaction.

In the current study, logistic regression revealed that the presence of blood on suction was a significant risk factor for developing sore throat after intubation. However, other variables did not significantly affect the incidence of such problem.

In another study, the duration of intubation was a significant risk factor for having POST on univariate and multivariate analysis (P=0.002 and 0.006, respectively). Other variables, including sex, age, and blood detection on suction, were not significant on the same analysis (P>0.05) [1].

El‐Boghdadly et al. [20] reported that large-sized tracheal tube, prolonged intubation, airway trauma during manipulation, and female sex, along with age, were independent risk factors for POST.

Another Korean study has reported that intracuff pressure more than 17 cmH₂O along with the presence of cough at emergence was a significant risk factor for POST in the included cases [21].

Furthermore, statistical analysis revealed only three significant risk factors for POST: age older than 60 years (P=0.01), application of an endotracheal tube no. 7.0 (P=0.02), and throat-pack use (P=0.04) [22].

The heterogenicity in risk factors of POST could be attributed to different patient criteria, anesthetic technique, operative time, and anesthetist experience.

Our study has some limitations: first of all, the lack of control, or placebo group. Also, it was a single-center study. We did not use fiber-optic bronchoscopy to assess the degree of tissue damage. Therefore, multiple studies from different centers, including placebo groups, should be conducted in the near future.

Conclusion

Based on our study findings, intravenous administration of dexamethasone appears to be more promising than lidocaine in decreasing the incidence of POST.

Financial support and ponsorship

Nil.

Conflicts of interest

There are no conflict of interests.

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