Anaesthesia, 1990, Volume 45, pages 306308
Postoperative sore throat A comparison after premedication with papaveretum/hyoscine or temazepam
S . VALENTINE, F. K. McVEY
A. C O E
Summary A randomised double-blind trial was conducted to study the use of two commonly used premedication regimens and the subsequent incidence of sore throat. Fifty adult patients who underwent routine surgery were anaesthetised in a standard fashion after premedication with papaveretum and scopolamine or temazepam, and interviewed after operation to assess the presence of sore throat. A significantly higher incidence of sore throat was associated with the use of papaveretum and scopolamine.
Key words Premedication; papaveretum, hyoscine, temazepam. Complications; sore throat. Sore throat is a common postoperative complaint. The incidence varies from 5 to go%, and the condition occurs most frequently in patients whose trachea has been intubated.’,’ Many other factors, including use of lubricants,’~’ pharyngeal and type of tracheal tube3” have been implicated. It is possible that the mucosal drying effect of anticholinergic premedication might increase the incidence of throat dryness and discomfort,’ but we could find no data in the literature on this specific question. However, anticholinergic premedication is in such widespread use that the findings would be relevant to routine anaesthetic practice. The aim of this study was to compare two commonly used premedication regimens, one of which contained an anticholinergic agent, on the incidence of postoperative dry and sore throat.
Method The local ethics committee approved the study. Fifty adult patients scheduled to undergo surgery that required tracheal intubation and mechanical ventilation in the supine position were studied. Patients were excluded if there was a pre-existing sore throat or upper respiratory tract infection, or if dental, ear, nose and throat, or neck surgery Was planned. Eligible patients were allocated randomly to one of two groups by tossing a coin. Group one received papaveretum 10 to 20 mg with hyoscine 0.2 to 0.4 mg intramuscularly depending upon body weight, one hour before operation. Group two received temazepam 10 to 30 mg orally one hour before operation. Both regimens are in routine practice, and
nursing staff and patients were not informed of the trial or its purpose. All patients were anaesthetised in a standardised fashion. General anaesthesia was induced with thiopentone 3-5 mg/ kg and the patient was paralysed with vecuronium 0.1 mg/ kg. The trachea was intubated with a red rubber cuffed oral Magill tube (8.0 mm int rnal diameter for females and 9.0 mm internal diameter f r males). All tracheal tubes were lubricated with K-Y jelly. Any patient who required more than one laryngoscopy to effect intubation was excluded. The cuff of the tracheal tube was inflated with air until a seal was just achieved and then readjusted if a leak occurred later. Anaesthesia was maintained with 66% nitrous oxide in oxygen, and isoflurane. Analgesia was provided by fentanyl 1-3 pg/kg. Supplemental doses of vecuronium were given as required. Any change in the patient’s position from supine, or the insertion of a nasogastric tube or pharyngeal pack, led to exclusion from the trial. Muscular relaxation was reversed at the end of surgery in all cases with atropine 20 pg/kg and neostigmine 40 pg/kg. Pharyngeal secretions were sucked clear with a plastic Yankauer sucker and the patient’s trachea was extubated after return of spontaneous ventilation. A Guedel airway was inserted after extubation and removed when no longer tolerated by the patient. Both groups were prescribed papaveretum and metoclopramide as required postoperatively. A second investigator, unaware of the premedication given, interviewed the patients between 12 and 24 hours later using a standardised interview format that employed
S. Valentine, MB, ChB, FFARCS, F.K. McVey, MB, ChB, FCAnaes, A. Coe, MB, BS, FFARCS, Registrars, Department of Anaesthetics, Bristol Royal Infirmary, Bristol BS2 8HW. Correspondence should be addressed to F.K. McVey, 12 Osborne Road, Clifton, Bristol BS8 2HB. Accepted 13 September 1989. 0003-2409/90/040306
+ 03 $03.00/0
@ 1990 The Association of Anaesthetists of G t Britain and Ireland
Postoperative sore throat
Table 3. Incidences of dry or painful throat on indirect (direct)
Table 1. Interview format.
‘Hello, I’m Dr , an anaesthetist. I’ve come to see how you are after your general anaesthetic.’ I . ‘How are you feeling?’ 2. ’Do you have any discomfort or pain? If so whereabouts and how would you describe it?’ This question was repeated until all complaints had been elicited. 3. ‘Do you have or have you had a dry or a sore throat?’ 4. ‘Do you smoke at all? How many?
both indirect and direct questions (Table 1). Each interview was conducted as privately as possible in the ward setting. After a general introduction, the patients were asked if they had any pain or discomfort anywhere. They were then asked directly if *dry o r painful throat was present. The patients’ responses were recorded immediately on a form designed for that purpose. Statistical analysis was performed using Student’s t-test, Chi-square test and Fisher’s exact test, as appropriate.
Results The general characteristics of the 50 patients and the nature of their operations are shown in Table 2. There are no significant differences between the groups in terms of gender, age, smoking habits, duration of anaesthesia o r peri-operative fluids received. The incidence of sore throat in patients WHO received papaveretum and hyoscine premedication was 38% (95% confidence intervals (CI) 19-57%) on indirect questioning, and 67% (95% CI 45-85%) on direct questioning. In contrast, only 19% (95% CI 7 4 0 % ) of patients who were premedicated with temazepam had a dry throat on direct questioning only, and none complained of a sore throat. This difference is statistically significant for both direct questioning (p < 0.01) and indirect questioning (p < 0.01; Table 3 ) . N o patient who smoked complained of a dry o r painful throat after operation.
Discussion Our results show that there is a significant degree of postoperative throat discomfort, either soreness or dryness, Table 2. General characteristics of patients and nature of
Male : female Mean age, years (SD) Smokers (more than 5 cigarettes daily) Peri-operative fluids Number receiving Volume, ml, mean (SD)
Group 1 (n = 24)
Group 2 (n = 26)
10:14 44 (16) 7
11:15 53 (19) 6
1717 (589) 1682 (815)
Orthopaedic General surgical Gynaecological
Minutes, mean (SD)
Group I , papaveretum and hyoscine; Group 2, temazepam.
p t 0 . 0 1 for both direct and indirect questioning. Group 1, papaveretum and hyoscine; Group 2, temazepam. associated with intramuscular opiate and anticholinergic premedication up to 24 hours after surgery. The groups were well matched for age, sex and duration of operation. Anaesthetic and interview technique were standardised to minimise the effects of other factors implicated in the genesis of sore throats. Throat discomfort contributes to the physical ailments suffered by the postoperative patient. In 1960, an editorial called for increasing recognition of minor sequelae of anaesthesia and greater efforts to reduce their incidence.8 The use of anticholinergic drugs in anaesthetic practice began in 1861 to counteract the excessive respiratory tract secretions during open-drop ether anaesthesia, and remains in widespread use. A survey in 1978 found that 62.7% of anaesthetists in U K used anticholinergic premedication r ~ u t i n e l y . Suggested ~ beneficial properties of anticholinergic premedication include protection against vagal overactivity, an antiemetic action, amnesia, sedation and reduced incidence of hiccups.Ifl Falick” found that premedication with glycopyrronium significantly decreased the occurrence of complications due to respiratory tract secretions and advocated the continued use of anticholinergic premedication. HoltI2 and later Gravenstein and Anton” suggested avoidance of anticholinergic premedication for minor surgical procedures, and studies by Kessell,14and Leighton and Sanders,I5 showed no adverse effects from omission of routine anticholinergic premedication. The incidence of sore throat after anaesthesia varies between 5 and 100%.2.4~1~2fl Hartsell and Stepheni6found that only 5% of patients volunteered the complaint, and that sore throat was rarely a primary complaint during the interview. However, Cronin el a1.I9 found that more than half of all general surgical patients complained of some degree of sore throat; 6 % of these regarded it as the most unpleasant part of their recovery. Similarly Edmonds-Seal et aL4 found that 38% of intubated patients complained of sore throat and almost all patients in his series had a dry mouth which was ‘often distressing to the patient.’ Antisialagogues had been used and the patients were relatively dehydrated. Many factors affect the incidence, including the interview method used, to elicit the complaint.20 Intubation of the trachea is associated with approximately a four-fold . ~ , ~size ~ and increase of sore throat in many ~ t u d i e s . ~The shape of the tracheal tube, and the size, shape and pressure of the cuff have been studied with varying conclusions.2,3,5,6J8J Lubricants appear to make little difference to the incidence, but those that contain a local anaesthetic may make the problem w ~ r s e . ’ , ~ ~Use , l ~ ,of * ~suxamethonium with subsequent myalgia is associated with sore throat.23 Other factors include use of a pharyngeal pack,z nasogastric tube,2.16.18 movement of the head during ~ u r g e r y , ~ ~ . ~ ~ straining on the tracheal tube, and the prone p o ~ i t i o n . ~As .~*
S . Valentine, F.K. McVey and A . Coe
far as possible, these factors were standardised in the present study and we believe that the difference between the groups was the result of inclusion of hyoscine in premedication of patients in g r o u p l .
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