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From the Department of Anesthesiology, University of Occupational and Environmental Health, School of Medicine, Fukuoka, Japan.
Dr. Kouichiro Minami, Department of Anesthesiology, University of Occupational and Environmental Health, School of Medicine, 1-1, Iseigaoka, Yahatanishiku, Kitakyushu, Fukuoka, 807-8555, Japan. Phone: +81-93-691-7265; Fax: +81-93-601-2910; E-mail: kminami{at}med.uoeh-u.ac.jp
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Abstract |
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Method: Patients were randomly assigned to have treatment with ketoprofen (ketoprofen group) or to have placebo tape treatment (control group). Postoperative analgesia was obtained by continuous epidural infusion of local anesthetics, and no narcotics were administered intraoperatively or postoperatively. All patients were interviewed postoperatively after 12–20 hr using a scoring scale questionnaire. Sore throat was scored as 0=no sore throat, 1=minimal, 2=mild, 3=moderate, 4=severe.
Results: In the control group, 16 of 32 patients had a sore throat. In the ketoprofen group, less patients (ten of 31 patients) had a sore throat (not significant). The severity of sore throat was alleviated significantly in the ketoprofen group (P <0.05).
Conclusion: This study suggests the pain caused by tracheal intubation is relieved by intraoperative topical use of transdermal ketoprofen.
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Introduction |
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Ketoprofen {2-(3-benzoylphenyl) propionic acid} belongs to the propionic acid derivatives, which represent a group of analgesic, anti-inflammatory, and antipyretic nonsteroidal anti-inflammatory drugs (NSAIDs).17 It has been reported that ketoprofen is useful for postoperative analgesia.18 Recently, application to the skin has been shown to be a suitable delivery route for ketoprofen in the transdermal therapeutic system.19 However, transdermal application of NSAID to prevent postoperative sore throat has not been reported. Thus, the aim of our study was to determine whether transdermal application of ketoprofen during surgery prevents sore throat.
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Methods |
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Triazolam 0.25 mg po was administered preoperatively. Prior to the induction of general anesthesia, an epidural catheter was placed and a local anesthetic was administered intraoperatively and postoperatively in the epidural space. General anesthesia was induced with propofol 2–2.5 mg•kg–1 iv after preoxygenation. Laryngoscopy and tracheal intubation were facilitated with vecuronium 1.0 mg•kg–1 iv. Endotracheal tubes with a low-pressure cuff (SheridanTM; Kendall Healthcare Products Co., Inc., Mansfield, MA, USA) were used. Male and female patients received 8.0-mm and 7.5-mm inner diameter tubes, respectively. A lidocaine (10%) containing lubricant was used on endotracheal tubes. Intubations were performed by the same anesthesia resident (supervised by faculty) with a curved laryngoscope. The resident was blinded to group assignment. A patient was eliminated from the study if more than two attempts at passage of the endotracheal tube were required. The cuff was inflated just to the point of obtaining a seal in the presence of positive airway pressure. Intracuff pressure was adjusted every 30 min using a pressure gauge (Digital P-V GaugeTM, IMP, Inc., Cleveland, Ohio, USA) to limit nitrous oxide-related intracuff pressure increase.20 After induction, a transdermal ketoprofen 20 mg (Mohrus® tape; Hisamitsu Pharmaceutical Co., Inc., Tosu, Japan) tape or a placebo tape was applied to the anterior skin of the neck and removed just before emergence (Figure
). Ventilation was adjusted to maintain PaCO2 at 35–40 mmHg. Orogastric or nasogastric tubes were not placed. Anesthesia was maintained with isoflurane 0.5–1.5% in combination with nitrous oxide 67% in oxygen. Supplemental analgesia was obtained by bolus injection of 2% mepivacaine into the epidural space every 50 min. Adequate muscle relaxation for the surgical procedure was obtained by epidural anesthesia, and no additional muscle relaxant was used. Oropharyngeal suction before extubation was done under direct vision to avoid trauma to the pharyngeal mucosal tissue. Postoperative analgesia was obtained by continuous epidural infusion of local anesthetics, and no narcotics were administered intraoperatively or postoperatively. Patients' soreness of throat was evaluated 12–20 hr postoperatively by a blinded member of the research team using the questionnaire presented in Tables I and II, modified after the questionnaire suggested by Harding and McVey.21 Adverse effects on the digestive system and skin, if any, were noted (Table I). Impairment of platelet function was suspected if the patient had excessive postoperative bleeding.
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=0.05, a minimum of 31 patients was required in each group. |
Results |
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). No patient was eliminated from the study because of difficult intubation.
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). The difference was not statistically significant.
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). No effect on the skin was attributed to ketoprofen adhesive tape and the patients did not present any gastrointestinal complications at the time of interview. Postoperative bleeding did not increase during the hospitalization.
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Discussion |
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Ketoprofen is a cyclooxygenase inhibitor, is said to stabilize lysosomal membranes and may antagonize the actions of bradykinin.22 Cordero et al. has reported that transdermal ketoprofen has a high permeation flux due to its high intrinsic solubility.19 These properties may be attributable to decreased inflammation as a result of ketoprofen application per se and lead to the reduction of sore throat. We chose the anterior skin of the neck for application of the drug because we expected that a higher local tissue concentration of ketoprofen would be achieved when applied in proximity to the larynx. However, the reduction of sore throat could be also due to the systemic absorption of ketoprofen, in which case the application to other sites may be also effective. Plus, it is unclear whether the treatment effect was obtained locally or systemically. It will be interesting to compare the benefits of transdermal application at different sites vs the systemic administration by the usual po/pr/iv routes.
We conclude that postoperative sore throat is frequent in anesthetized patients undergoing routine endotracheal intubation and intraoperative transdermal ketoprofen applied over the larynx effectively mitigates this undesirable side effect.
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Acknowledgments |
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Revision received August 29, 2001. Accepted for publication May 29, 2001.
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References |
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2
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3
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14
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18
Basto ER, Waintrop C, Mourey FD, Landru JP, Eurin BG, Jacob LP. Intravenous ketoprofen in thyroid and parathyroid surgery. Anesth Analg 2001; 92: 1052–7.
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20
Nguyen Tu H, Saidi N, Lieutaud T, Bensaid S, Menival V, Duvaldestin P. Nitrous oxide increases endotracheal cuff pressre and the incidence of tracheal lesions in anesthetized patients. Anesth Analg 1999; 89: 187–90.
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