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GENERAL ARTICLES

Does the Timing of Tracheal Intubation Based on Neuromuscular Monitoring Decrease Laryngeal Injury? A Randomized, Prospective, Controlled Trial

Thomas Mencke, MD^*, Matthias Echternach, MD, Peter K. Plinkert, MD, Ulrich Johann, MD, Nazan Afan, MD, Hauke Rensing, MD, Gabriele Noeldge-Schomburg, MD^*, Heike Knoll, MD, and Reinhard Larsen, MD

*Department of Anaesthesia and Intensive Care Medicine, University of Rostock, Rostock, Germany; Department of Otorhinolaryngology, Department of Anaesthesia and Intensive Care Medicine, University of the Saarland, Homburg/Saar, Germany

Address correspondence and reprint requests to Thomas Mencke, MD, Department of Anesthesia and Intensive Care Medicine, University of Rostock, Schillingallee 35, 18057 Rostock, Germany. Address e-mail to thomas.mencke{at}uni-rostock.de.

Vocal cord injuries (VCI) and postoperative hoarseness (PH) are common complications after general anesthesia. Poor muscle relaxation at the moment of tracheal intubation may result in VCI. There is a large interindividual variation in neuromuscular depression after administration of neuromuscular blocking drugs. Therefore, the optimal individual timing of tracheal intubation based on neuromuscular monitoring (monitoring) may decrease VCI. In this prospective trial, 60 patients were randomized into 2 groups: Monitoring group: tracheal intubation at maximum block based on monitoring after atracurium 0.5 mg/kg and 2-min group: tracheal intubation 2 min after injection of atracurium 0.5 mg/kg. Intubating conditions were evaluated with the Copenhagen score. VCI were examined by stroboscopy before and 24 and 72 h after surgery. PH was assessed at 24, 48, and 72 h after surgery by a standardized interview. Excellent intubating conditions were significantly increased in the monitoring group compared with the 2-min group: 8 versus 2 patients, respectively (P = 0.036). The incidence of PH between the study groups was comparable: 7 (monitoring) versus 8 patients (2-min) (P = 0.860). Similar findings were observed for VCI: 9 versus 5 patients; respectively (P = 0.268); type of VCI: thickening of the vocal cords: 8 (monitoring) versus 5 (2-min) patients (P = 0.423), hematomas: 2 patients in each group (not significant). The present study demonstrated that neuromuscular monitoring improved endotracheal intubating conditions. However, tracheal intubation at maximum intensity of neuromuscular block was not associated with a decrease in vocal cord injuries.

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