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Year : 2017 Month : January Volume : 6 Issue : 5 Page : 364-368

PREVALENCE OF POST-EXTUBATION LARYNGOSPASM IN CHILDREN GETTING PROPHYLACTIC INTRAVENOUS LIDOCAINE DURING TONSILLECTOMY - A CROSS SECTIONAL STUDY.

Jayakumar Cristhudas1, Satheedevi Parameswaran2

1Associate Professor, Department of Anaesthesiology, Government Medical College, Manjeri.
2Additional Professor, Department of Anaesthesiology, Government Medical College, Manjeri.

CORRESPONDING AUTHOR

Dr. Jayakumar Cristhudas,
Email : drjkanaesthesia@gmail.com

ABSTRACT

Corresponding Author:
Dr. Jayakumar Cristhudas,
Associate Professor,
Department of Anaesthesiology,
Government Medical College,
Manjeri, Malappuram (Dist.),
Kerala.
E-mail: drjkanaesthesia@gmail.com

ABSTRACT

BACKGROUND

Tonsillectomy with or without adenoidectomy is one of the most frequent surgical procedures that are carried out globally in children and it is associated with maximum incidence of laryngospasm during extubation. The present study is on prevalence of post-extubation laryngospasm in children getting intravenous lidocaine as prophylaxis.

Objectives - Primary objective is to study the prevalence of laryngospasm in children getting intravenous lidocaine as prophylaxis during extubation following tonsillectomy. Secondary objectives are to study the prevalence of coughing in children getting intravenous lidocaine as prophylaxis during extubation following tonsillectomy and to study the haemodynamic response during extubation in children getting intravenous lidocaine as prophylaxis of post-extubation laryngospasm following tonsillectomy.

MATERIALS AND METHODS

175 children who were given intravenous lidocaine 2 mg/kg before extubation after tonsillectomy were studied. The prevalence of laryngospasm, coughing and haemodynamic changes during extubation were studied.

RESULTS

4 children out of 175 had mild laryngospasm. 18 children had coughing after extubation. 5 children (2.9%) had mild coughing, 10 children (5.7%) had moderate coughing and 3 children (1.7%) had severe coughing. The prevalence of laryngospasm in our study population is 2.3%. The prevalence of coughing was 10.3%. Heart rate, systolic, and diastolic pressure changes following extubation were compared with pre-extubation values using paired t test. There was no significant change in heart rate, systolic, and diastolic pressure. The p value is more than 0.05. The oxygen saturation was maintained > 97%.

CONCLUSION

The prevalence of laryngospasm in children getting intravenous lidocaine as prophylaxis during extubation following tonsillectomy is 2.3%. The prevalence of coughing is 10.3%. There was no significant change in heart rate, systolic, and diastolic pressure and oxygen saturation.

KEYWORDS

Lidocaine, Laryngospasm, Tonsillectomy.

BACKGROUND

Tonsillectomy with or without adenoidectomy is one of the most frequent surgical procedures that are carried out globally in children. Although it is a common procedure, it presents risks and challenges for both the surgeon and the anaesthetist. Tonsillectomy is an elective procedure with more than average mortality approximately 1 per 10-20000 cases.(1) Children had a twofold higher incidence of fatal respiratory events in the postoperative period.

In a study conducted by Brown. K. A in 2011 in children undergoing adenotonsillectomy, 44% of mortality or

profound brain injury resulted from postoperative respiratory complications.(2) Among the respiratory causes of cardiac arrest, airway obstruction from laryngospasm was 6%. Laryngospasm is a serious complication which was the most common seen in anaesthesia during induction, intubation or extubation. It is a frequently encountered complication in children undergoing upper airway surgery which if left untreated can lead to an increase in morbidity and mortality. The reported incidence of laryngospasm in patients aged 0-9 years is 17.4% and is even higher in children between 1 and 3 months of age.(3)

The incidence of laryngospasm after adenoidectomy and tonsillectomy is reported to be as high as 21-26%.(4) Children are more prone to airway obstruction as they have a narrow laryngeal and tracheal lumen that may be blocked by mucosal oedema.(5) The complications resulting from laryngospasm are cardiac arrest 0.5%, obstructive negative pressure pulmonary oedema 4%, pulmonary aspiration 3%, bradycardia 6% and oxygen desaturation 61%.(6) Various techniques to prevent or treat laryngospasm include intravenous lidocaine which is easily available in operation theatre and cheaper. It has an additional advantage of blunting pressor response during laryngoscopy and intubation.

Its side effects are dose related and not seen at plasma concentration less than 5 µg/mL. The present study aims at the efficacy of a commonly available drug lidocaine in preventing laryngospasm. The primary outcome of our study is prevalence of post-extubation laryngospasm in children getting IV lidocaine as prophylaxis. We also study the prevalence of coughing in children getting IV lidocaine during extubation and also the haemodynamic changes associated with extubation.

 

Aim of Study

Objectives

Primary objective was to study the prevalence of laryngospasm in children getting intravenous lidocaine as prophylaxis during extubation following tonsillectomy.

Secondary

  1. To study the prevalence of coughing in children getting intravenous lidocaine as prophylaxis during extubation following tonsillectomy
  2. To study the haemodynamic response during extubation in children getting intravenous lidocaine as prophylaxis of post-extubation laryngospasm following tonsillectomy.

 

MATERIALS AND METHODS

The study was conducted in 175 children undergoing tonsillectomy with or without adenoidectomy aged between 3 and 12 years in the Department of Anaesthesiology, Government Medical College Trivandrum. Informed written consent from patients was taken. Result values were recorded using a pre-set proforma.

 

Study Design

Cross sectional study to study the prevalence of laryngospasm in children getting intravenous lidocaine as prophylaxis during extubation following tonsillectomy.

 

Study Population

Children getting IV lidocaine before extubation while undergoing tonsillectomy and satisfying inclusion and exclusion criteria.

 

Inclusion Criteria

  1. Children in the age 3-12 years.
  2. ASA I-II.

 

Exclusion Criteria

Children with history of

  1. Congenital heart disease.
  2. Bronchial asthma.
  3. Recent respiratory tract infection.

 

MATERIALS AND METHODS

After obtaining the approval from the hospital ethical community and the written informed consent from the patients, the study was conducted at Government Medical College, Trivandrum. Children with 3-12 years of age undergoing tonsillectomy and satisfying inclusion and exclusion criteria were included in the study. Informed written consent was taken from parents after explaining details of the study. Noninvasive monitors such as pulse oximeter, ECG, automated non-invasive blood pressure and end tidal CO2 monitor were used. All children had an appropriate sized IV cannula. The children were pre-oxygenated with 100% oxygen for 3 minutes and then premedicated with Inj. Atropine 0.02 mg/kg IV, Inj. Midazolam 0.02 mg/kg IV and Inj. Metoclopramide 0.2 mg/kg IV. General anaesthesia was induced with Sevoflurane 1-2%, Inj. Propofol 2 mg/kg IV, Inj. Fentanyl 2 µg/kg IV and Inj. Vecuronium 0.1 mg/kg IV and intubated with appropriate size RAE tube. Anaesthesia was maintained with Sevoflurane 2%, Nitrous oxide 60% and oxygen 40% and IPPV. The neuromuscular blockade was antagonised with Inj. Neostigmine 0.05 mg/kg and Inj. Atropine 0.02 mg/kg. The heart rate, blood pressure and oxygen saturation 3 minutes after reversal is noted. 3 minutes after reversal IV lidocaine 2 mg/kg was given and the haemodynamic parameters like heart rate, systolic and diastolic blood pressures were noted. Then, children were ventilated with 100% oxygen for 90 seconds and then children were extubated. After extubation 100% O2 was given for 3 minutes and then 40% O2 through venture face mask. For 10 minutes following extubation, heart rate, blood pressure, oxygen saturation, breathing pattern, severity of coughing and laryngospasm were noted.

Coughing was evaluated using the modified four-point scale: 0= None, 1= Slight, 2= moderate, 3= severe.

Laryngospasm was graded using the four-point scale: 0=No laryngospasm, 1=Stridor during inspiration, 2=Total occlusion of cords, 3=Cyanosis. Cases with laryngospasm were immediately treated by giving positive pressure ventilation with 100% O2, jaw thrust and Inj. Propofol 0.5 mg/kg. The haemodynamic parameters heart rate, blood pressures and O2 saturation were monitored at 1-minute interval for 10 minutes after Extubation.

Statistical Analysis

Data were analysed using computer software Statistical Package for Social Sciences (SPSS) latest version. Data were expressed in its frequency and percentage as well as mean and standard deviation. Paired t test was used to compare pre-extubation mean value and value at 1-10 minutes after extubation.

 

RESULTS

 

Age in Years

Frequency

Percentage

3

9

5.1

4

6

3.4

5

14

8

6

42

24

7

42

24

8

12

6.9

9

13

7.4

10

8

4.6

11

13

7.4

12

16

9.1

Total

175

100

Table 1. Age Distribution of Study Groups

 

Sex

Frequency

Percentage

Female

55

31.4

Male

120

68.6

Total

175

100

Table 2. Sex distribution of Study Groups

 

 

N

Min

Max

Mean

Std.Deviation

Age in years

175

3

12

7.40

2.41

Weight in KG

175

15

45

24.31

8.66

Dose (Minimum)

175

30

120

70.54

22.98

Table 3. Table showing Mean Age,

Weight and Duration of Surgery

 

The mean weight of children was 24.3 Kg and the mean duration of surgery was 70 minutes.

 

Laryngospasm

Frequency

Percentage

95% CI

Absent

171

97.7

 

Grade1

4

2.3

0.8-5.7%

Grade 2

0

0

 

Grade3

0

0

 

Total

175

100

 

Table 4. Frequency and Percentage of Laryngospasm

 

The prevalence of laryngospasm in our study population was 2.3% with a 95 % CI between 0.8 -5.7%.

 

Coughing

Frequency

Percentage

Absent

157

89.7

Grade1

5

2.9

Grade2

10

5.7

Grade 3

3

1.7

Total Children with coughing

18

10.3

Table 5. Frequency and Percentage of Coughing

 

18 children had coughing after extubation, 5 children had mild coughing, 10 had moderate coughing and 3 children had severe coughing.The prevalence of coughing was 10.3% with a 95% CI between 6.38 -16.01%. 89.7% of children did not have coughing after extubation.


 

 

 

N

Heart Rate

Paired Comparison with base Line Value

Mean

SD

Mean difference

Se

P

HR pre

175

102.42

10.316

 

 

 

HR 1

175

102.65

10.275

0.229

0.132

0.085

HR 2

175

102.66

10.439

0.240

0.144

0.097

HR 3

175

102.60

10.373

0.177

0.120

0.141

HR 4

175

102.57

10.327

0.143

0.079

0.072

HR 5

175

102.54

10.323

0.114

0.066

0.084

HR 6

175

102.44

10.352

0.017

0.059

0.771

HR 7

175

102.47

10.251

0.051

0.071

0.727

HR 8

175

102.35

10.314

0.074

0.085

0.386

HR 9

175

102.29

10.19

0.137

0.105

0.195

HR 10

175

102.22

10.16

0.200

0.200

0.139

Table 6. Changes in Heart Rate Following Extubation

 

 

 

N

SBP

Paired Comparison with Baseline Value

Mean

SD

Mean Difference

Se

P

SBP PRE

175

102.99

5.217

 

 

 

SBP1

175

103.28

5.361

0.286

0.152

0.061

SBP2

175

103.26

5.392

0.263

0.149

0.080

SBP3

175

103.15

5.518

0.160

0.126

0.206

SBP4

175

103.10

5.372

0.103

0.-089

0.250

SBP 5

175

102.93

5.299

0.069

0.087

0.432

SBP6

175

102.96

5.317

0.034

0.112

0.759

SBP7

175

102.98

5.247

0.011

0.111

0.918

SBP8

175

102.88

5.285

0.114

0.118

0.333

SBP9

175

102.82

5.284

0.171

0.116

0.140

SBP10

175

102.78

5.194

0.217

0.144

0.132

Table 7. Systolic Blood Pressure Changes during Extubation

 

 

N

DBP

Paired Comparison with Base Line Value

Mean

SD

Mean Difference

Se

P

DBP Pre

175

66.17

3.982

     

DBP1

175

66.47

4.45

0.297

0.163

0.07

DBP2

175

66.45

4.197

0.274

0.149

0.067

DBP3

175

66.14

4.21

0.034

0.122

0.779

DBP4

175

66.14

3.975

0.034

0.103

0.74

DBP5

175

66.34

3.985

0.171

0.105

0.104

DBP6

175

66.31

3.968

0.137

0.103

0.186

DBP7

175

66.19

4.027

0.023

0.11

0.836

DBP8

175

65.98

3.812

0.194

0.128

0.132

DBP9

175

65.95

3.959

0.217

0.116

0.064

DBP10

175

65.95

3.977

0.217

0.122

0.076

Table 8. Changes in Diastolic BP during Extubation

 

 

 

N

SPO2

Mean

SD

SPO2 1

175

97.91

0.83

SPO2 2

175

98.02

0.77

SPO2 3

175

98.12

0.77

SPO2 4

175

98.57

0.68

SPO2 5

175

98.89

0.45

SPO2 6

175

99.09

0.45

SPO2 7

175

99.15

0.36

SPO2 8

175

99.47

0.5

SPO2 9

175

99.47

0.5

SPO2 10

175

99.69

0.46

Table 9. Change in SPO2 following Extubation

 

DISCUSSION

Tonsillectomy with or without adenoidectomy is a common procedure in children. But it is associated with highest incidence (20-26%) of laryngospasm. Various measures for prevention and treatment of laryngospasm have been studied. This study was a cross sectional study carried out at Government Medical College Trivandrum. 175 children in the age group 3-12 years (ASA I and II) scheduled for tonsillectomy with or without adenoidectomy were included in this study. Children with history of respiratory tract infection within 4 weeks and history of asthma were excluded from the study. Children were anaesthetised with Sevoflurane, Propofol and Vecuronium and intubated with RAE tubes of appropriate size. At the end of the procedure, 3 minutes after reversal, IV lidocaine 2 mg/kg was given and 90 seconds later the children were extubated. Then, the prevalence of laryngospasm, coughing, changes in blood pressure, heart rate and O2 saturation after extubation were studied. In our study, children in the age group 5-7 years constituted 56%. This is in agreement with the study by J. Aleeson Glover - “The Incidence of Tonsillectomy in School children”. According to him, the highest incidence is in the period 5-7 years, the peak being in the 6th year.

Our study group included 68.6% boys and 31.4% girls. According to study by Glover JA, the incidence of tonsillectomy is higher in boys than in girls.(7) In our study, in 175 children who got IV Lidocaine 2 mg/kg 90 seconds before extubation, only 4 children (2.3%) had laryngospasm. This laryngospasm was mild and easily treated with 100% O2, positive pressure ventilation and propofol. According to study by Baraka et al, IV Lidocaine controls extubation laryngospasm in children. Intravenous Lidocaine 2% 2 mg/kg given 60 seconds before extubation reduced the incidence of laryngospasm to 0 % from 20% in children undergoing tonsillectomy.(8)

In our study, the 18 children out of 175 developed post-extubation coughing. The prevalence of coughing in children getting IV lidocaine during extubation was 10.3%. Out of 18 children, 5 (2.9%) had mild coughing, 10 (5.7%) had moderate coughing and 3 (1.7%) had severe coughing. According to study by Yukioka H Et al, IV lidocaine is a cough suppressant during tracheal intubation in elderly patients and incidence of coughing after giving 2 mg/kg lidocaine IV 1 minute before intubation was 10%. In their 2nd study, the incidence of coughing was only 7% with the same dose of lidocaine given 1 minute before intubation.(9)

A previous study by Bidwai and colleagues also showed decreased incidence of coughing after giving lidocaine before extubation and the dose given was 1 mg/kg 2% Lidocaine IV 2 minutes prior to extubation. This prevented significant change in BP, heart rate and reduced coughing.(10)

Study by CS Sanikop et al showed that IV Lidocaine produced little increase in heart rate and BP compared to placebo and also did not produce fall in SPO2 after extubation in children who got lidocaine before extubation.(11) These results were similar to our study.

CONCLUSION

The prevalence of laryngospasm in children undergoing tonsillectomy and getting IV lidocaine during extubation was 2.3%. It was much less than the usual incidence of laryngospasm 20-26% in children undergoing tonsillectomy. The prevalence of coughing in children getting IV lidocaine during extubation is 10.3%. There was no significant change in heart rate, systolic or diastolic blood pressure. The P value was more than 0.05. The oxygen saturation (SPO2) was maintained at > 97%. There was no fall in SPO2 after extubation.

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