Breast surgeries are commonly performed under general anaesthesia with laryngeal mask airway. Post operatively sore-throat (POST), hoarseness and cough are common complaints following breast surgery. Even though these symptoms resolve spontaneously, prophylactic management of POST is recommended to improve the quality of post-anaesthesia care.  Various drugs like intravenous dexamethasone, ketamine, magnesium sulphate have been studied for their efficacy to reduce the incidence of sore-throat. Nebulization or local application of local anaesthetic has been used to reduce the development of POST [1]. Trans- tracheal administration of local anaesthetic is used in awake fiberoptic intubation.[2] This study is performed to assess the effectiveness of single dose 5ml of  trans-tracheal lignocaine 4% on the incidence of POST, hoarseness and cough.

Methods

This prospective, randomised, double blinded study will be conducted after obtaining approval from hospital ethical committee, clinical trial registry of India (CTRI)  and informed written consent from patients.  Patients aged 18–60 years, of the American Society of Anaesthesiologists (ASA) physical status 1–2, undergoing breast cancer surgeries lasting 2-3h under general anaesthesia with laryngeal mask airway will be included in this study. Patients with anticipated difficult airway, history of allergy to the test drug, who required more than one attempt  at insertion and those with pre-operative sore throat or already on analgesics or steroids (systemic or inhaled) will be excluded from the study.

The patients will be randomly assigned into two equal groups, T and S, based on computer-generated random sequence of numbers. Concealment will be achieved by closed envelope technique. Standard general anaesthesia protocol will be followed in both groups. Patients will receive oral ranitidine 150 mg, metoclopramide10 mg, and alprazolam 0.25 mg on the night before surgery and ranitidine 150 mg and metoclopramide 10 mg on the morning of

surgery.

In the operation theatre, intravenous (IV) cannula will be inserted and monitoring with electrocardiography, noninvasive blood pressure monitor, and pulse oximeter will be done. Patients in group T will receive a trans-tracheal injection of 5ml of 4% lignocaine and group S will receive a trans-tracheal injection of 5ml of 0.9% saline. Patients will be pre oxygenated with 100% O₂; glycopyrrolate 0.2 mg, midazolam 2 mg and fentanyl 2 µg/kg will be given intravenously.  They will then be induced with IV propofol 1.5–2.5 mg/kg till there is loss of response to verbal command and the patient becomes apnoeic. Classic LMA size 3/4 will be inserted after full deflation. The patient will be maintained on O₂, N2O and isoflurane 0.5%–1.5%. LMA cuffs will be filled with 20/30 ml of room air. If >1attempt will be required for insertion, the patients will be excluded from the study.

The trans-tracheal injection will be given by a single consultant anaesthetist. The cuff pressure will be measured and will be set to 25 cmH2O using Portex cuff inflator (manufacturer: Smiths Medical International Ltd., UK) in both groups. Patients will be maintained on spontaneous ventilation. Rise in heart rate and/or mean arterial pressure more than 20% from the baseline value will be initially treated with increasing the inspired concentration of isoflurane to 1.5%–2%. If there was no response, IV 20 μg boluses of fentanyl will be given. Toward the end of the surgery, IV ondansetron 4 mg and IV paracetamol 1 g will be given to all patients. On completion of the surgery, LMA will be removed after suctioning and deflating the cuff. Four hours after surgery all patients will receive oral paracetamol 650 mg 8th hourly. Patients will be given rescue analgesia with IV tramadol 1mg.kg−1 if the patient complained of pain. The total dose of tramadol given in the first 24 h will be noted for both groups. Postoperative sore throat, cough and hoarseness will be monitored  by the anaesthetist who will be blinded and the responses will be noted at 0, 2, 4, 12, and 24 h.