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ORIGINAL ARTICLE
Year : 2020  |  Volume : 9  |  Issue : 1  |  Page : 31-36

Comparative evaluation of 2% lignocaine viscous gargling and intravenous lignocaine for insertion of laryngeal mask airway


Department of Anaesthesiology and Critical Care, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India

Date of Submission31-May-2018
Date of Decision28-Nov-2019
Date of Acceptance29-Nov-2019
Date of Web Publication2-Jun-2020

Correspondence Address:
Peyyety Janaki Subhadra
Associate Professor, Department of Anaesthesiology and Critical Care, Sri Venkateswara Institute of Medical Sciences, Tirupati 517 507, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JCSR.JCSR_121_19

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  Abstract 


Background: Few studies have compared the efficacy of 2% lignocaine viscous gargling with intravenous lignocaine given prior to induction with propofol and fentanyl for laryngeal mask airway (LMA) insertion for minor-to-moderate elective surgeries.
Methods: Sixty patients were randomized into two groups: Group V (n = 30) and Group I (n = 30). Group V patients gargled with 25 ml 2% lignocaine for 2 min in sitting position. Three minutes after gargling, they were preoxygenated in supine position and fentanyl (1 μg/kg) was administered intravenously. In Group I, patients were preoxygenated and fentanyl (1 μg/kg) and lignocaine (1.5 mg/kg) were simultaneously administered intravenously. Sixty seconds after fentanyl, both the groups received propofol (2 mg/kg) intravenously over 30 s, and 90 s later, LMA insertion was attempted. Conditions of LMA insertion, SpO2and haemodynamic parameters, were recorded before and after the insertion of LMA at the end of the 1st, 2nd and 3rd min.
Results: Both the groups were comparable demographically. There was no statistically significant difference in terms of conditions of LMA insertion, haemodynamic parameters and duration of apnea between the groups. However, there was a statistically significant fall in systolic blood pressure, diastolic blood pressure and mean arterial pressure 1, 2 and 3 min after LMA insertion from baseline values within each group.
Conclusions: Both intravenous lignocaine and gargling with 2% viscous lignocaine were equally effective and safe adjuvants when administered before induction with propofol and fentanyl for providing adequate conditions for LMA insertion.

Keywords: Fentanyl, laryngeal mask airway, lignocaine viscous gargling, propofol


How to cite this article:
Rao M H, Chaitanya J, Subhadra PJ. Comparative evaluation of 2% lignocaine viscous gargling and intravenous lignocaine for insertion of laryngeal mask airway. J Clin Sci Res 2020;9:31-6

How to cite this URL:
Rao M H, Chaitanya J, Subhadra PJ. Comparative evaluation of 2% lignocaine viscous gargling and intravenous lignocaine for insertion of laryngeal mask airway. J Clin Sci Res [serial online] 2020 [cited 2020 Jul 11];9:31-6. Available from: http://www.jcsr.co.in/text.asp?2020/9/1/31/285708




  Introduction Top


For minor-to-moderate surgical procedures, laryngeal mask airway (LMA) proved to be a useful alternative to provide general endotracheal anaesthesia. LMA is a supraglottic airway device[1] which allows spontaneous ventilation, as well as intermittent positive pressure ventilation with an airway pressure <20 cm H20.[2] LMA insertion requires adequate mouth opening and minimal upper airway reflexes such as coughing, gagging or laryngospasm.[3]

Intravenous anaesthesia is preferred for this purpose as it takes less time when compared to inhalational anaesthesia.[4],[5] Among the intravenous agents, propofol has been preferred the most because of its potential suppressor effects on upper airway reflexes.[2],[3],[6] When used alone without premedication, propofol provides adequate conditions for LMA insertion,[7],[8] but these doses cause cardiorespiratory depression.[8],[9]

Many adjuvant drugs have been tried to decrease the dose of propofol so as to minimise its cardiovascular side effects and yet produce the same depth of anaesthesia required for LMA insertion. These include opioids, muscle relaxants,[10],[11],[12],[13] intravenous agents,[14],[15] inhalation agents and topical local anaesthetics[16],[17] as well. However, to the best of our knowledge, few studies were done using the viscous lignocaine gargling as an adjuvant to induction with propofol (2 mg/kg)[18] and fentanyl (1 μg/kg)[10] to assess the LMA insertion conditions.

A randomized prospective study was under taken to compare the airway conditions for LMA insertion and haemodynamic stability provided by 2% lignocaine viscous gargling with IV lignocaine given before propofol (and fentanyl) induction.


  Material And Methods Top


This prospective randomised study was conducted in Sri Venkateswara Institute of Medical Sciences, a tertiary care university teaching hospital, after obtaining approval from the Institutional Ethics Committee. Informed written consent was taken from all study participants in the study. Sixty patients belonging to the American Society of Anesthesiologists (ASA) physical status Grade I and II[19] with no history of allergies to study drugs and aged between 18 and 60 years, undergoing different types of elective surgical procedures (general surgery, urology, surgical oncology and surgical gastroenterology) of short duration, which did not require endotracheal intubation, were included into the study.

Exclusion criteria included patients not willing to participate in the study, patients with predicted difficult airway, pregnant and lactating mothers, patients at risk of regurgitation or aspiration, patients with cervical spine disease, with mouth opening <2.5 cm, who were morbidly obese, and patients with upper respiratory tract infection in past 10 days, ischemic heart disease, controlled hypertension and oral surgeries.

Before the initiation of the study, these 60 patients were randomised by computer-generated random number sequence and sealed opaque envelope technique into two groups of 30 in each: Group V (received 2% lignocaine viscous gargling 6 min prior to the propofol induction) and Group I (received lignocaine 1.5 mg/kg IV 60 s prior to propofol induction).

All patients were kept nil by mouth overnight and were premedicated with ranitidine 150 mg and alprazolam 0.25 mg, both given orally the night before surgery.

Patients were shifted to the operating room and monitoring was started with electrocardiogram, pulse oximetry and noninvasive blood pressure (NIBP). Baseline values of heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial pressure (MAP) were recorded. Intravenous access was established with an 18 G cannula under local anaesthesia.

Due to the different routes of the drug (topical gargling vs. intravenous) administration, the drugs were given at a slightly different time points during the study period so as to get the benefit of peak effect of the drug (6 min after gargling of lignocaine viscous and 3 min after iv lignocaine) for studying the effects on LMA insertion conditions.

Meanwhile, anaesthesia was maintained by 50% of O2 in nitrous oxide (N2O) with 1.5% sevoflurane with a fresh gas flow of 8 L/min and patients were ventilated manually via face mask when required, otherwise, allowed to breath spontaneously. LMA of appropriate size was inserted and cuff inflated with appropriate amount of air, LMA was inserted by a single operator and conditions of insertion were noted by the same person. Following insertion of LMA, anaesthesia was maintained for the rest of the surgical procedure with 1.5% sevoflurane and 50% N2O in O2 in all the patients.

Proper placement of LMA was confirmed by auscultation over trachea and chest (for any sounds of airway obstruction), observation of reservoir bag movement of Bain circuit, absence of gastric insufflation by auscultation, absence of audible leak on gentle IPPV and capnography.

Gagging on insertion of LMA [Table 1] was classified into four categories: Grade 0– no gagging, 1: Gagging settled spontaneously in <30 s, Grade 2 : A further dose of induction agent required and Grade 3: Suxamethonium 0.1 mg/Kg was required to allow manual ventilation.[20] In those patients where Grade 3 gagging were to be encountered, suxamethonium 0.1 mg/kg[21] was to be given to insert the LMA and manual ventilation was to be done till spontaneous recovery of respiration. If any complications were to be encountered those patients were excluded from the study. Conditions for LMA insertion[21] were classified based on the presence or absence of gagging, laryngospasm, coughing and number of passes required for LMA insertion [Table 2].
Table 1: Grading of gagging

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Table 2: Evaluation of laryngeal mask airway insertion conditions

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HR, NIBP and SpO2 were recorded as (T0), and at 1 min (T1), 2 min (T2), and 3 min (T3) after LMA insertion.

Statistical analysis

Patient data variables were summarized as means and standard deviations. Comparison between two groups of continuous variables such as mean age, weight, HR, SBP, DBP and MAP was done with two tailed unpaired student t-test. Categorical variables between the two groups were compared by Chi-square test. Intragroup variables were analyzed with repeated measures analysis of variance. All statistical analysis was done by using Statistical Package for Social Sciences (SPSS) Version 20 statistical software [IBM SPSS Statistics for Windows, Version 20.0. IBM Corp., Armonk, NY]. A P-value <0.05 was considered to be statistically significant.


  Results Top


There was no significant difference between the two groups with regards to age, gender distribution, body weight, ASA physical status grading and Mallampati grading[22] [Table 3].
Table 3: Demographic data

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There was no statistically significant difference between the two groups with regards to the incidence of gagging, laryngospasm and coughing, number of attempts required for LMA insertion, mean duration of apnoea after induction and also conditions of LMA insertion [Table 4].
Table 4: Comparison of incidence of gagging, laryngospasm and coughing, number of attempts required for laryngeal mask airway insertion, mean duration of apnea after induction and conditions of laryngeal mask airway insertion

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Haemodynamic changes were comparable in both groups at baseline, 1, 2 and 3 min after LMA insertion, with regards to SBP, DBP and MAP. There was a significant fall in these values within each group from baseline to after LMA insertion values (P < 0.01). Changes in the HR did not show any statistically significant difference between the groups at the measured time points. There was a slight fall in HR within each group from baseline values to after LMA insertion values but this difference was not statistically significant (P > 0.05) [Table 5].
Table 5: Comparison of trends of haemodynamic changes between the groups

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  Discussion Top


We compared the airway conditions for LMA insertion provided by 2% lignocaine viscous gargling or IV lignocaine before induction with propofol and fentanyl and haemodynamics before insertion and for 3 min after insertion in both the groups.

The conditions of LMA insertion, in terms of lack of gagging, laryngospasm, coughing and minimum number of attempts were similar in both groups and no statistically significant difference was found between the groups.

The dose of propofol (2 mg/kg)[18] used in our study, along with fentanyl (1 μg/kg)[13] (and with either of the study drugs) was adequate for LMA insertion in most of the patients. This dose of propofol (2 mg/kg) for induction (in combination with fentanyl) was based up on the findings of earlier studies.[18],[23] The dose of fentanyl (1 μg/kg) was based on what was used in another study[10] Fentanyl, when given 30 s before a bolus propofol, provided optimum jaw relaxation and mouth opening observed 90 s after propofol injection. The predetermined periods of 30 s and 90 s were based on data from toher studies.[10],[24]

Lignocaine when given intravenously was found to be effective in minimizing the pressor response to laryngoscopy and intubation.[25] It was found to be effective in suppressing the pressor response/airway reflexes during LMA insertion also. The dose of IV lignocaine (1.5 mg/kg) used in our study was similar to that used in other studies.[14],[15] Intravenous lignocaine, 1.5 mg/kg was given at a time that is 3 min before LMA insertion, which would coincide with the peak effect of the drug.[20],[25]

Sparse data are available in the literature which evaluated viscous lignocaine as an adjuvant for insertion of LMA under general anaesthesia. It has been used facilitate oropharyngeal or airway instrumentation[26],[27] (for endoscopy procedures). In one previous study it was shown that viscous lignocaine was an effective adjuvant for attenuating the presser response to laryngoscopy and tracheal intubation.[28] We have chosen viscous lignocaine as one of the adjuvants in our study as it is cheap, easily available, with minimal side effects. To the best of our knowledge, no one has evaluated its effectiveness as an adjuvant or sole agent to attenuate reflexes or presser responses for the purpose of LMA insertion. The dose of 2% viscous lignocaine for gargling was taken as 25 ml and gargling done for full 2 min was based on the study done by Stoelting.[28] This gargling was timed in such a way that it would be completed 5–6 min prior to LMA insertion and the LMA insertion would coincide with peak effect of drug.[26],[29]

Both groups were comparable with regards to mean age, gender distribution, body weight, ASA physical status grading, Mallampati grading and surgical procedures.

Grade 1 gagging was observed in 3 patients (gagging settled spontaneously in <30 s) and Grade 2 gagging was observed in 2 patients, in each group. None of the patients in either group had Grade 3 gagging, coughing or laryngospasm during LMA insertion.

In Group V, the LMA was inserted in first attempt in 25 patients and in second attempt in 5 patients. In Group I, LMA was inserted in first attempt in 27 patients and in second attempt in 3 patients. None of the patients required more than 2 attempts in our study for LMA insertion which indicates the facilitation of ease of insertion by the drugs studied.

LMA insertion conditions were found to be excellent in 23 patients, good in 5 patients, poor in 2 patients in Group V and excellent in 24 patients, good in 4 patients, poor in 2 patients in Group I and there was no statistically significant difference was found in this regard. None of the patients in either group showed unacceptable conditions in LMA insertion. There was no statistically significant difference in the duration of apnea after induction between the 2 groups.

There was no significant difference in HR within each group or between the two groups in both pre induction baseline values or post LMA insertion values at 1, 2, and 3 min respectively.

The baseline values and post LMA insertion values of systolic, diastolic and MAPs between the two groups were comparable. However, there was a significant fall in SBP, DBP and mean arterial blood pressure,

1 min after insertion of LMA through to 3 min after insertion within each group from baseline values (P value <0.01). This significant fall could be attributable to the haemodynamic suppression properties of propofol itself.

Throughout the study, we have not observed any rise in haemodynamic parameters suggestive of sympathetic stimulation. This shows that our technique of induction with propofol (2 mg/kg) and fentanyl (1 μg/kg) along with either gargling with viscous lignocaine or IV lignocaine provided adequate depth of anaesthesia and favorable conditions for LMA insertion.

The lack of significant difference in the parameters studied i.e., conditions of LMA insertion, respiratory and haemodynamic parameters, between viscous lignocaine group and IV lignocaine group, suggests that both these adjuvants are equally effective and safe.

It would probably be useful to find out whether the dose of propofol (with or without fentanyl) could further be reduced from 2 mg/kg while using adjuvants. Such reduction in the dose of propofol (while taking help of adjuvants like viscous lignocaine or IV lignocaine 1.5 mg/kg to suppress the airway reflexes) could be very useful to provide adequate level of anaesthesia for LMA insertion or airway instrumentation in patients with compromised haemodynamics where even a minor degree of haemodynamic fluctuation is undesirable.

Another limitation of our study was that we did not measure the blood levels of lignocaine after gargling with viscous lignocaine. Most of the 30 patients in group V had spat out the remaining viscous liquid (mixed with saliva) but none of them had shown any signs of local anaesthetic overdose clinically during the study.

We conclude that both 2% viscous lignocaine for gargling and intravenous lignocaine were equally effective and safe adjuvants when administered before induction with propofol and fentanyl for providing adequate conditions for LMA insertion and stable haemodynamics.



Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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