Users Online: 354 Home Print this page Email this page Small font sizeDefault font sizeIncrease font size  
Home | About us | Editorial board | Search | Ahead of print | Current issue | Archives | Submit article | Instructions | Subscribe | Contacts | Login 


RSACP wishes to inform that it shall be discontinuing the dispatch of print copy of JOACP to it's Life members. The print copy of JOACP will be posted only to those life members who send us a written confirmation for continuation of print copy.
Kindly email your affirmation for print copies to [email protected] preferably by 30th June 2019.

 

 
Table of Contents
ORIGINAL ARTICLE
Year : 2016  |  Volume : 32  |  Issue : 2  |  Page : 168-171

Effect of magnesium sulfate nebulization on the incidence of postoperative sore throat


Department of Anaesthesiology and Critical Care, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India

Date of Web Publication10-May-2016

Correspondence Address:
Monu Yadav
Department of Anaesthesiology and Critical Care, Nizam's Institute of Medical Sciences, Hyderabad, Telangana
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9185.173367

Rights and Permissions
  Abstract 


Background: Postoperative sore throat (POST) is a well-recognized complication after general anesthesia (GA). Numerous nonpharmacological and pharmacological measures have been used for attenuating POST with variable success.
Aims and Objectives: The present study was conducted to compare the efficiency of preoperative nebulization of normal saline and magnesium sulfate in reducing the incidence of POST following GA.
Materials and Methods: Following institutional ethical committee approval and written informed consent, a prospective randomized double-blinded study was conducted in 100 cases divided into two equal groups. Patients included in the study were of either gender belonging to American Society of Anesthesiologist (ASA) status 1 or 2 undergoing elective surgery of approximately 2 h or more duration requiring tracheal intubation. Patients in Group A are nebulized with 3 ml of normal saline and the patients in Group B are nebulized with 3 ml of 225 mg isotonic nebulized magnesium sulfate for 15 min, 5 min before induction of anesthesia. The incidence of POST at rest and on swallowing and any undue complaints at 0, 2, 4, and 24 h in the postoperative period are evaluated.
Results: There is no significant difference in POST at rest during 0th, 2nd and 4th h between normal saline and MgSO4. Significant difference is seen at 24th h, where MgSO4lessens POST. There is no significant difference in POST “on swallowing” during 0th and 2nd h between normal saline and MgSO4. Significant difference is seen at 4th h, where MgSO4has been shown to lessen POST.
Conclusions: MgSO4significantly reduces the incidence of POST compared to normal saline.

Keywords: Intratracheal intubation, magnesium sulfate, pharyngitis


How to cite this article:
Yadav M, Chalumuru N, Gopinath R. Effect of magnesium sulfate nebulization on the incidence of postoperative sore throat. J Anaesthesiol Clin Pharmacol 2016;32:168-71

How to cite this URL:
Yadav M, Chalumuru N, Gopinath R. Effect of magnesium sulfate nebulization on the incidence of postoperative sore throat. J Anaesthesiol Clin Pharmacol [serial online] 2016 [cited 2021 May 13];32:168-71. Available from: https://www.joacp.org/text.asp?2016/32/2/168/173367


  Introduction Top


Modern anesthesia is safe, versatile, and indispensable to the patient. Now-a-day, quality assurance of anesthesia is becoming increasingly important for improving postoperative outcome. Therefore, efforts are on to decrease the incidence and severity of other anesthesia-related complications such as postoperative nausea-vomiting and postoperative sore throat (POST), apart from the management of postoperative pain.

Postoperative sore throat is a well-recognized complication that remains unresolved in patients undergoing tracheal intubation for general anesthesia (GA) with a reported incidence of 6.6-90%. [1] It also increases the duration of hospital stay, especially in day care surgeries. [2]

Numerous nonpharmacological and pharmacological measures have been used for attenuating POST with variable success. Among the nonpharmacological methods, smaller sized tracheal tubes, careful airway instrumentation, minimizing the number of laryngoscopy attempts, intubation after the full relaxation of the larynx, gentle oropharyngeal suctioning, filling the cuff with an anesthetic gas mixture, [3] minimizing intracuff pressures <20 mm Hg, [3] and extubation when the tracheal tube is fully deflated, have been reported to decrease the incidence of POST.

Pharmacological measures for attenuating POST are inhalation of beclomethasone and fluticasone, gargling with azulene sulfonate, aspirin, ketamine, benzydamine hydrochloride and licorice, local spray of benzydamine hydrochloride, and intracuff administration of alkalized lignocaine. [4],[5]

It is known that N-methyl-D-aspartate (NMDA) has a role in nociception and inflammation. [6],[7] NMDA receptors are found in peripheral nerves and the central nervous system. [8],[9] Magnesium is also an antagonist of the NMDA receptor ion channel. [10] We planned to study the efficacy of magnesium sulfate nebulization to reduce the incidence of POST. The drug is easily available and nebulization may be simple, cost-effective method to decrease POST symptoms.


  Material and Methods Top


Following institutional ethical committee approval and written informed consent, the prospective randomized double-blinded study was conducted in 100 cases. With the level of significance (alpha) = 0.05, and power of 80%, sample size required was 40 per group. To accommodate any exclusion, 50 patients from each group were selected.

Patients included in study were of either gender, aged between 18 and 60 years belonging to American Society of Anesthesiologist (ASA) 1 or 2 status undergoing elective surgery of approximately 2 h or more duration requiring tracheal intubation. Patients with neuromuscular disease, allergy or hypersensitivity of drugs, undergoing neck surgeries, and laparoscopic surgeries were excluded. Patients were allocated randomly to two groups, Group A and Group B. Simple randomization was done using SPSS software (IBM, SPSS Statistics 21).

All patients were kept fasting overnight and premedicated with oral alprazolam 0.5 mg and ranitidine 150 mg on night before surgery and on the morning of surgery.

Five minutes prior to the induction of anesthesia, patients in Group A were nebulized with 3 ml of normal saline and the patients in Group B were nebulized with 3 ml of 225 mg isotonic nebulized magnesium sulfate for 15 min. The solution for nebulization was administered by an anesthesiologist not associated with the management of the case. The anesthesiologist anesthetizing the case and those recording the scores were blinded to it.

In the operation theater, after connecting the patient to standard monitoring intravenous access was secured.

Anesthesia was induced with fentanyl 2 mcg/kg and thiopentone 5 mg/kg. Tracheal intubation was facilitated by atracurium 0.6 mg/kg, and the trachea intubated with soft seal cuffed sterile polyvinyl chloride tracheal tube (Portex Limited CT 21, 6JL, UK) of 7 mm inner diameter in female and 8 mm in male patients. The tracheal tube cuff was inflated with air.

The cuff pressure was checked just after intubation using handheld tracheal cuff pressure monitor (Portex Cuff Inflator/Pressure Gauge, SIMS Portex, Hythe, Kent, UK) and then every half hourly till end of surgery and maintained at 20 cm of H 2 O.

Ventilation was controlled, and no nasogastric tube was inserted. Anesthesia was maintained with 66% nitrous oxide in oxygen with 1% of isoflurane and intermittent doses of atracurium and fentanyl as required. The last dose of atracurium was given 20 min prior to extubation. At the end of surgery, the muscle relaxation was reversed with a combination of neostigmine 0.05 mg/kg and glycopyrrolate 0.01 mg/kg. The trachea was extubated after extubation criteria were met, and the patients were shifted to postanesthesia care unit.

Presence of sore throat was noted at rest and on swallowing immediately after extubation, and 2 h, 4 h, and 24 h postoperatively. In the postoperative ward, patients were also monitored for any drug-related side effects.

Data were expressed as mean, and 95% confidence interval of mean. Test of normality (Kolmogorov-Smirnov, Shapiro-Wilk) was done for continuous variables (height, weight, age. Categorical data (gender) were expressed as frequency of occurrence. Comparison of continuous data between groups was done using ANOVA of means. Comparisons of categorical data between groups were done using Pearson Chi-square, continuity correction, likelihood ratio, Fisher's exact test; P < 0.05 was considered statistically significant. IBM SPSS-21 was used for statistical analysis.


  Results Top


The age, gender distribution and weight were comparable in the two groups [Table 1]. There was no significant difference in POST at rest at 0 th , 2 nd , and 4 th h between normal saline and magnesium sulfate. Significant difference was seen at 24 th h with Chi square test, where MgSO 4 lessened POST, but not with Fisher's Exact test [Table 2].
Table 1: Demographic data presented as either mean with 95% CI for mean or as numbers

Click here to view
Table 2: Postoperative sore throat "at rest"

Click here to view


No significant difference in POST was observed "on swallowing" was observed between normal saline and magnesium sulfate at 0 and 2 h. Significant difference was seen at 4 th and 24 h with both Chi square and Fisher's Exact tests, where MgSO 4 lessened POST [Table 3].
Table 3: Postoperative sore throat "on swallowing"

Click here to view


With respect to age, there was no significant difference in POST at swallowing between normal saline and magnesium sulfate. Exception to age category was 30-45 years; at 2 nd h and 4 th h "on swallowing" are significant, where there was increased incidence of POST in patients nebulized with normal saline.

With respect to gender, there was no significant difference in POST "at rest" and "on swallowing" between normal saline and magnesium sulfate.


  Discussion Top


Incidence of POST after GA and tracheal intubation is reported to be 0-50%. [1] In spite of being a self-limiting entity, it is considered as one of the most common undesirable anesthesia-associated problems. [1] The contributing factors for POST include sex, age, gynecological surgery, use of succinylcholine, larger tracheal tubes, cuff design, and intracuff pressures. [2],[3],[11]

POST can be multifactorial in origin, including mechanical injury during laryngoscopy and intubation, continuous pressure by the inflated tracheal tube cuff on tracheal mucosa causing damage and dehydration of the mucosa. Not much literature is available about the use of nebulized magnesium sulfate for attenuation of POST.

Our results in the control group were consistent with previous findings. We avoided using lignocaine jelly, reducing the confounding factors, thereby reducing POST incidence. Kori et al., [12] Maruyama et al. [13] found a higher incidence and severity of POST, where lignocaine 2% jelly has been used as a lubricant on the tracheal tube.

In our study, magnesium sulfate lessened the pain during swallowing at 4 h postsurgery compared to normal saline. The effectiveness of magnesium lozenges 30 min preoperatively was studied by Borazan et al. [14] who found it effective reducing both incidence and severity of POST in the immediate postoperative period. His results are also comparable to ours Borazan et al. [15] also showed the effectiveness of preoperative magnesium sulfate lozenge in reducing the incidence and severity of POST.

Gupta et al. [16] also assessed the efficiency of preoperative nebulization of magnesium sulfate and found that the incidence and severity of POST were reduced at rest and on swallowing at all-time points (P < 0.05).

Sore throat related to orotracheal tube might be a consequence of localized trauma, leading to aseptic inflammation of the pharyngeal mucosa. Magnesium being an NMDA receptor antagonist, has a role in preventing NMDA receptor-mediated nociception and inflammation [17] and thereby POST. In a recently published study by Ahuja et al., [18] a similar mechanism of action was proposed for preoperative nebulization of ketamine. Similar to Blitz et al. [19] who used nebulized magnesium sulfate for treatment of acute asthma, we too did not find any either local or systemic adverse outcomes. The drawback of our study was the absence of the measurements of serum magnesium levels making it difficult to rule out the contribution of systemic effects of magnesium. Moreover, comparing the doses used in the treatment of preeclampsia and eclampsia, the dose used in our study is very low and has been used in the form of nebulization, absorption for which has been shown to be variable and low (10%). [20]


  Conclusion Top


POST is common in the patients undergoing GA with an tracheal tube for routine surgical cases for up to 24 h. The relative risk for POST in normal saline nebulized group "on swallowing" was 2.33 at 4 th h and 9.0 at 24 h compared to MgSO 4 nebulization.

We conclude that magnesium sulfate significantly reduces the incidence of POST compared to normal saline.

 
  References Top

1.
Sumathi PA, Shenoy T, Ambareesha M, Krishna HM. Controlled comparison between betamethasone gel and lidocaine jelly applied over tracheal tube to reduce postoperative sore throat, cough, and hoarseness of voice. Br J Anaesth 2008;100:215-8.  Back to cited text no. 1
    
2.
Higgins PP, Chung F, Mezei G. Postoperative sore throat after ambulatory surgery. Br J Anaesth 2002;88:582-4.  Back to cited text no. 2
    
3.
Ratnaraj J, Todorov A, McHugh T, Cheng MA, Lauryssen C. Effects of decreasing endotracheal tube cuff pressures during neck retraction for anterior cervical spine surgery. J Neurosurg 2002;97:176-9.  Back to cited text no. 3
    
4.
Canbay O, Celebi N, Sahin A, Celiker V, Ozgen S, Aypar U. Ketamine gargle for attenuating postoperative sore throat. Br J Anaesth 2008;100:490-3.  Back to cited text no. 4
    
5.
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-blind study. Anesth Analg 2006;103:1001-3.  Back to cited text no. 5
    
6.
Lin CY, Tsai PS, Hung YC, Huang CJ. L-type calcium channels are involved in mediating the anti-inflammatory effects of magnesium sulphate. Br J Anaesth 2010;104:44-51.  Back to cited text no. 6
    
7.
Zhu MM, Zhou QH, Zhu MH, Rong HB, Xu YM, Qian YN, et al. Effects of nebulized ketamine on allergen-induced airway hyperresponsiveness and inflammation in actively sensitized Brown-Norway rats. J Inflamm (Lond) 2007;4:10.  Back to cited text no. 7
    
8.
Tan PH, Yang LC, Chiang PT, Jang JS, Chung HC, Kuo CH. Inflammation-induced up-regulation of ionotropic glutamate receptor expression in human skin. Br J Anaesth 2008;100:380-4.  Back to cited text no. 8
    
9.
Carlton SM. Inflammation, role of peripheral glutamate receptors. Encyclopedia of Pain. Berlin, Heidelberg: Springer; 2007. p. 984-7.  Back to cited text no. 9
    
10.
Turpin F, Dallérac G, Mothet JP. Electrophysiological analysis of the modulation of NMDA-receptors function by D-serine and glycine in the central nervous system. Methods Mol Biol 2012;794:299-312.  Back to cited text no. 10
    
11.
Hu B, Bao R, Wang X, Liu S, Tao T, Xie Q, et al. The size of endotracheal tube and sore throat after surgery: A systematic review and meta-analysis. PLoS One 2013;8:e74467.  Back to cited text no. 11
    
12.
Kori K, Muratani T, Tatsumi S, Minami T. Influence of endotracheal tube cuff lubrication on postoperative sore throat and hoarseness. Masui 2009;58:342-5.  Back to cited text no. 12
    
13.
Maruyama K, Sakai H, Miyazawa H, Iijima K, Toda N, Kawahara S, et al. Laryngotracheal application of lidocaine spray increases the incidence of postoperative sore throat after total intravenous anesthesia. J Anesth 2004;18:237-40.  Back to cited text no. 13
    
14.
Borazan H, Kececioglu A, Okesli S, Otelcioglu S. Oral magnesium lozenge reduces postoperative sore throat: A randomized, prospective, placebo-controlled study. Anesthesiology 2012;117:512-8.  Back to cited text no. 14
    
15.
Borazan H, Kececioglu A, Okesli S, Otelcioglu S. Oral magnesium lozenge reduces postoperative sore throat: A randomized, prospective, placebo-controlled study. Anesthesiology 2012; 117:512-8.  Back to cited text no. 15
    
16.
Gupta SK, Tharwani S, Singh DK, Yadav G. Nebulized magnesium for prevention of postoperative sore throat. Br J Anaesth 2012;108:168-9.  Back to cited text no. 16
    
17.
Lin CY, Tsai PS, Hung YC, Huang CJ. L-type calcium channels are involved in mediating the anti-inflammatory effects of magnesium sulphate. Br J Anaesth 2010;104:44-51.  Back to cited text no. 17
    
18.
Ahuja V, Mitra S, Sarna R. Nebulized ketamine decreases incidence and severity of post-operative sore throat. Indian J Anaesth 2015;59:37-42.  Back to cited text no. 18
[PUBMED]  Medknow Journal  
19.
Blitz M, Blitz S, Hughes R, Diner B, Beasley R, Knopp J, et al. Aerosolized magnesium sulfate for acute asthma: A systematic review. Chest 2005;128:337-44.  Back to cited text no. 19
    
20.
Hess DR. Nebulizers: Principles and performance. Respir Care 2000;45:609-22.  Back to cited text no. 20
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]


This article has been cited by
1 The Effect of preoperative nebulized: Magnesium sulfate versus lidocaine on the prevention of post-intubation sore throat
Alshaimaa Abdel Fattah Kamel,Olfat Abdelmoniem Ibrahem Amin
Egyptian Journal of Anaesthesia. 2020; 36(1): 1
[Pubmed] | [DOI]
2 Magnesium and Pain
Hyun-Jung Shin,Hyo-Seok Na,Sang-Hwan Do
Nutrients. 2020; 12(8): 2184
[Pubmed] | [DOI]
3 A Comparative Study of Three Nebulized Medications for the Prevention of Postoperative Sore Throat in the Pediatric Population
Raham Hasan Mostafa,Ashraf Nabil Saleh,Mostafa Mansour Hussein
The Open Anesthesia Journal. 2018; 12(1): 85
[Pubmed] | [DOI]
4 Magnesium sulfate in pediatric anesthesia: the Super Adjuvant
Ramón Eizaga Rebollar,María V. García Palacios,Javier Morales Guerrero,Luis M. Torres,Mark Thomas
Pediatric Anesthesia. 2017;
[Pubmed] | [DOI]



 

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
  Material and Methods
  Results
  Discussion
  Conclusion
   References
   Article Tables

 Article Access Statistics
    Viewed4134    
    Printed109    
    Emailed3    
    PDF Downloaded826    
    Comments [Add]    
    Cited by others 4    

Recommend this journal