Citation Information :
Modir H, Mahmoodiyeh B, Kamali A, Barsari FZ, Ranjbar S. Efficacy of gargling with Licorice extract, Ketamine, and Magnesium Sulfate before Laryngoscopy: Tracheal Intubation in Prevention of Sore Throat, Hoarseness, and Cough; a Randomized Clinical Trial. Indian J Respir Care 2023; 12 (1):62-66.
Background and objective: Tracheal intubation is considered to represent a major cause of trauma to the airway mucosa, which can give rise to a postoperative sore throat. This randomized clinical quality improvement trial on the well-established benefit of gargling with licorice extract, ketamine, and magnesium sulfate before laryngoscopy and tracheal intubation was undertaken to address how to prevent throat soreness, hoarseness, and cough.
Patients and methods: In a prospective, double-blind randomized controlled trials, 105 patients who were undergoing laryngoscopy and endotracheal intubation under general anesthesia were recruited. They were assigned into one of three intervention groups, including ketamine, licorice, and magnesium sulfate, using block randomization and requested to gargle twice for 15 seconds and 20 minutes before anesthesia induction and to spit out. Postoperative sore throat, cough, and hoarseness were recorded from endotracheal extubation at baseline (T0) every 10 minutes during recovery until T45 (45 minutes) and at initial 24-hour time points (2, 4, 8, 12, and 24 hours) later. Analysis of variance (ANOVA) and chi-squared tests was used for data analysis at a significance level of p = 0.05 in Statistical Package for the Social Sciences (SPSS) v20 (Chicago, Illinois, United States of America) software.
Results: The mean age of patients was 48.21 ± 9.21 years, and 57.1% were male. No statistically significant intergroup difference was observed in the study groups for oxygen saturation (SpO2), heart rate, blood pressure, and duration of surgery. Our results showed that less sore throat was found in the ketamine group at T8/T12 (8 and 12 hours after recovery (p < 0.05). In addition, no statistically significant intergroup difference was revealed in cough and hoarseness during the times studied (p > 0.05).
Conclusion: Our evidence confirmed that ketamine, licorice, and magnesium sulfate appeared to be able to effectively reduce pain, cough, and hoarseness and to be associated with similar hemodynamic changes, while the ketamine-treated subjects manifested a marked decrease in sore throat pain intensity with postoperative times of T8 and T12. Consequently, gargling with ketamine continues to demonstrably be put forward as a promising candidate to control postoperative sore throat but is as equal as other intervention drugs in terms of effectively controlling cough or hoarseness. Ultimately, the final choice relies on both patient acceptance and anesthesiologist preference.
Jung TH, Rho JH, Hwang JH, et al. The effect of the humidifier on sore throat and cough after thyroidectomy. Korean J Anesthesiol 2011;61(6):470–474. DOI: 10.4097/kjae.2011.61.6.470
Sinha R, Correia R, Gardner D, et al. Mucosal injury following short-term tracheal intubation: a novel animal model and composite tracheal injury score. Laryngoscope Investig Otolaryngol 2018;3(4):257–262. DOI: 10.1002/lio2.168
Ali S, Khan A, Ashfaq AD. Comparison of two different sizes of endotracheal tracheal tube for postoperative sore throat in breast cancer patients undergoing surgeries. Cureus 2021;13(1):e12896. DOI: 10.7759/cureus.12896
Prokakis C, Koletsis EN, Dedeilias P, et al. Airway trauma: a review on epidemiology, mechanisms of injury, diagnosis and treatment. J Cardiothorac Surg 2014;9(1):117. DOI: 10.1186/1749-8090-9-117
Anvari HM, Kazaj MA, Kolahdouzan K, et al. Effect of single dose of pregabalin on post tracheal intubation sore throat after general anesthesia. Arch Anesthesia Crit Care 2019;5(3):95–98. DOI: 10.18502/aacc.v5i3.1210
Kheirabadi D, Ardekani MS, Honarmand A, et al. Comparison prophylactic effects of gargling different doses of ketamine on attenuating postoperative sore throat: a single-blind randomized controlled trial. Int J Prev Med 2021;12:62. DOI: 10.4103/ijpvm.IJPVM_147_19
Sharma S, Bhardwaj V, Sharma S, et al. Dexamethasone to decrease post-anesthesia sore throat (POST) and hoarseness-which is the most effective route: intravenous, topical, or nebulization? A prospective randomized trial. Ain-Shams J Anesthesiol 2021;13(1):26. DOI: 10.1186/s42077-021-00144-8
Agarwal A, Gupta D, Yadav G, et al. An evaluation of the efficacy of licorice gargle for attenuating postoperative sore throat: a prospective, randomized, single-blind study. Anesth Analg 2009;109(1):77–81. DOI: 10.1213/ane.0b013e3181a6ad47
Ebneshahidi A, Mohseni M. Strepsils® tablets reduce sore throat and hoarseness after tracheal intubation. Anesth Analg 2010;111(4):892–894. DOI: 10.1213/ANE.0b013e3181d00c60
Miller RFL, Johns R. Miller anesthesia. Philadelphia: Churchill Livingstone; 2018.
Leite CDS, Bonafé GA, Carvalho Santos J, et al. The anti-inflammatory properties of licorice (glycyrrhiza glabra)—derived compounds in intestinal disorders. Int J Mol Sci 2022;23(8):4121. DOI: 10.3390/ijms23084121
Yang R, Yuan BC, Ma YS, et al. The anti-inflammatory activity of licorice, a widely used Chinese herb. Pharm Biol 2017;55(1):5–18. DOI: 10.1080/13880209.2016.1225775
Zorumski CF, Izumi Y, Mennerick S. Ketamine: NMDA receptors and beyond. J Neurosci 2016;36(44):11158–11164. DOI: 10.1523/JNEUROSCI.1547-16.2016
Zanos P, Gould TD. Mechanisms of ketamine action as an antidepressant. Mol Psychiatry 2018;23(4):801–811. DOI: 10.1038/mp.2017.255
Thoppil JV, Imanual SR. Efficacy of ketamine gargle for attenuating postoperative sore throat in patients undergoing general anaesthesia with endotracheal intubation. J Evol Med 2017;6(81):5707–5712. DOI: https://doi.org/10.22502/jlmc.v3i1.61
Panzer O, Moitra V, Sladen RN. Pharmacology of sedative-analgesic agents: dexmedetomidine, remifentanil, ketamine, volatile anesthetics, and the role of peripheral mu antagonists. Crit Care Clin 2009;25(3):451–469. DOI: 10.1016/j.ccc.2009.04.004
Arumugam S, Lau CSM, Chamberlain RS. Perioperative adjunct magnesium decreases postoperative opioid requirements—a meta-analysis. Int J Clin Med 2016;7(5):297–308. DOI: 10.4236/ijcm.2016.75032
Shah PN, Dhengle Y. Magnesium sulfate for postoperative analgesia after surgery under spinal anesthesia. Acta Anaesthesiol Taiwan 2016;54(2):62–64. DOI: 10.1016/j.aat.2016.06.003
Chattopadhyay S, Das A, Nandy S, et al. Postoperative sore throat prevention in ambulatory surgery: a comparison between preoperative aspirin and magnesium sulfate gargle - a prospective, randomized, double-blind study. Anesth Essays Res 2017;11(1): 94–100. DOI: 10.4103/0259-1162.186602
Kamel AAF, Ibrahem Amin OA. The effect of preoperative nebulized: magnesium sulfate versus lidocaine on the prevention of post-intubation sore throat. Egypt J Anaesth 2020;36(1):1–6. DOI: 10.1080/11101849.2020.1723330
Mostafa EA, Abdel Rahman AS, Mahmoud MD. Magnesium sulfate nebulizer versus ketamine nebulizer in decreasing incidence and severity of post operative sore throat with endotracheal intubation in adults. Egypt J Hosp Med 2018;73(8):7244–7250. DOI: 10.21608/EJHM.2018.18262
Ibrahim AN, Anis S. Licorice versus ketamine gargle for postoperative sore throat due to insertion of a double-lumen endobronchial tube. Egypt J Anaesth 2016;10(3):45–49. DOI: 10.4103/1687-9090.200283
Dhanger S, Vaidiyanathan B, Rajesh IJ, et al. Comparison of the efficacy of lignocaine viscous gargle versus ketamine gargle for the prevention of post-operative sore throat after classic laryngeal mask airway insertion: a prospective randomised trial. Airway 2018;1(1):13–16. DOI: 10.4103/ARWY.ARWY_5_18
Schachtel B, Aspley S, Shephard A, et al. Utility of the sore throat pain model in a multiple-dose assessment of the acute analgesic flurbiprofen: a randomized controlled study. Trials 2014;15:263. DOI: 10.1186/1745-6215-15-263
Bouroubi A, Donazzolo Y, Donath F, et al. Pain relief of sore throat with a new anti-inflammatory throat lozenge, ibuprofen 25 mg: a randomised, double-blind, placebo-controlled, international phase III study. Int J Clin Pract 2017;71(9):e12961. DOI: 10.1111/ijcp.12961
Kang HY, Seo DY, Choi JH, et al. Preventive effect of ketamine gargling for postoperative sore throat after endotracheal intubation. Anesth Pain Med 2015;10(4):257–260. DOI: 10.17085/apm.2015.10.4.257
Ruetzler K, Fleck M, Nabecker S, et al. A randomized, double-blind comparison of licorice versus sugar-water gargle for prevention of postoperative sore throat and postextubation coughing. Anesth Analg 2013;117(3):614–621. DOI: 10.1213/ANE.0b013e318299a650
Chan L, Lee ML, Lo YL. Postoperative sore throat and ketamine gargle. Br J Anaesth 2010;105(1):97. DOI: 10.1093/bja/aeq152
Jafari A, Salimi A, Safari F, et al. The effect of magnesium sulfate on sore throat following surgery in patients undergoing general anesthesia. Iranian Journal Of Anaesthesiology and Critical Care. 2013;35(3):36.