IJNHCR Journal

Introduction

Postoperative sore throat (POST) is one of the most common complications following the removal of the endotracheal tube after general anesthesia. Research indicates that the incidence of POST in patients under general anesthesia ranges from 21% to 70% [1]. The prolonged intubation during surgery can cause abrasion to the patient’s larynx, leading to laryngeal edema and pain. Patients often experience unbearable sore throat after the endotracheal tube is removed. Currently, there is no effective solution during the anesthesia recovery process, thus making the prevention of POST particularly important. Therefore, this study aims to assess the influencing factors of POST in order to prevent it, reduce the incidence of POST, and shorten the recovery time, thereby achieving comfortable nursing care, enhancing the patient’s medical experience, and improving medical satisfaction [2].

Materials and Methods

Design

This study was conducted as a cross-sectional, prospective descriptive study.

Study Setting and Sampling

This study was conducted in the Postoperative Recovery Room of the Nansha Division of The First Affiliated Hospital, Sun Yatsen University. The study population consisted of 355 patients. However, the study sample included only 271 patients because 34 patients were unable to respond coherently postoperatively, 16 patients could not cooperate due to postoperative delirium, 6 patients were transferred to the ICU after arriving in the recovery room, 9 patients experienced severe allergies in the recovery room, and 19 patients had incomplete data (Figure 1).

Inclusion and Exclusion Criteria

A convenience sampling method was employed to select postoperative patients who underwent general anesthesia in the anesthesia recovery room of a tertiary hospital in Guangzhou from January to June 2024 as the subjects of this study.

Inclusion Criteria

• All patients were over 18 years old and had good reading comprehension, language communication, and cognitive abilities;
• All patients voluntarily or according to medical advice accepted endotracheal intubation general anesthesia, rather than local or regional anesthesia;
• Patients with health conditions that might affect the results were typically excluded, such as those with severe complications or other diseases that affect the efficacy of anesthesia;
• Patients who were informed of their condition and consented to participated in this study.
• Patients with other preoperative laryngeal diseases and discomfort, such as vocal cord polyps, gastroesophageal reflux, etc.;
• Patients with severe mental or neurological diseases who could not cooperate to complete the survey;
• Allergies to specific drugs or adverse reactions in the history of anesthesia;
• Patients who needed to enter the ICU after surgery;
• Patients who were too weak to communicate;
• Patients who required reintubation;
• Patients who used double-lumen endotracheal tubes for intubation.

Exclusion Criteria

Instruments

The assessment tool was developed by the researchers through literature review and expert consultation. It is divided into two parts: general disease conditions and specialty-specific conditions. The general disease section includes factors such as type of surgery, age, gender, BMI, smoking history, surgical history, financial concerns, preoperative anxiety, cardiac function rating, airway rating, ASA classification, and whether hypothermia occurred during the perioperative period. The specialty-specific section includes factors such as whether the patient has a difficult airway, surgical position, intubation duration, number of suctioning episodes, number of coughing episodes, number of agitation episodes, whether there was delayed awakening, whether the endotracheal tube size was appropriate, use of steroid medications, and type of endotracheal tube [3-8].

Body Mass Index (BMI)

This is an indicator that measures the ratio of weight to height, used to assess whether the weight is within a normal range. The calculation formula is weight (in kilograms) divided by the square of height (in meters). Typically, a BMI value between 18.5 and 24 is considered within the normal range.

Cardiac Function Classification

It is divided into four grades. Grade I indicates no limitation of physical activity. Grade II indicates slight limitation of physical activity. Grade III indicates marked limitation of physical activity.

Grade IV indicates that any physical activity causes discomfort.

Airway Classification (Mallampati Grading)

It is divided into four grades, with higher grades generally indicating greater difficulty in intubation. Grade I: The soft palate, uvula, fauces, and hard palate are visible. Grade II: The soft palate, uvula, and hard palate are visible. Grade III: The soft palate and hard palate are visible. Grade IV: Only the hard palate is visible.

ASA Classification

It is divided into five grades. Grade I indicates a healthy individual. Grade II indicates mild or moderate systemic disease. Grade III indicates severe systemic disease with limitation of daily activities but without loss of working capacity. Grade IV indicates severe systemic disease with loss of working capacity. Grade V indicates critical illness.

Hamilton Anxiety Rating Scale (HAM-A)

The Hamilton Anxiety Rating Scale (HAM-A) is a clinical scale used to assess the severity of anxiety in individuals. It consists of 14 items that evaluate various anxiety symptoms, such as tension, fear, and muscle tension. Each item is scored on a scale of 0 to 4, with a total score ranging from 0 to 56. Higher scores indicate more severe anxiety symptoms. A total score above 29 indicates severe anxiety; above 21 indicates definite anxiety; above 14 indicates probable anxiety; and above 7 suggests possible anxiety. If the score is less than 6, the patient is considered to have no anxiety symptoms. In this study, HAMA scores of ≥7 were defined as anxiety. This scale is widely used in clinical assessments and research to determine the severity of anxiety [9].

Facial Visual Analogue Scale (F-VAS)

The Facial Visual Analogue Scale (F-VAS) was used to assess patients’ postoperative sore throat. The VAS is one of the most commonly used single-dimensional measurement tools for pain intensity. The scale primarily consists of a 100mm line, with one end representing ‘no pain at all’ and the other end representing ‘the most severe pain imaginable’ or ‘the worst pain possible’. Patients are asked to mark their pain level on this line, and any score above 0 indicates sore throat [10]. This method is sensitive, intuitive, simple to understand, and less influenced by other factors, making it widely used in clinical research.

Data Collection

One day before surgery, the researchers explained the purpose, methods, and significance of the study to the subjects and their families, obtaining their consent and support, and having them sign an informed consent form. The study involved asking patients about their basic medical history, the presence of preoperative sore throat, and the level of preoperative anxiety using a verbal questionnaire on the day before surgery. Patients with preoperative sore throat were excluded. The specialty-specific conditions were assessed on the day of surgery, and the patients’ sore throat was evaluated using the Facial Visual Analogue Scale (F-VAS) before they left the anesthesia recovery room after extubation. The study was conducted from January 2024 to June 2024.

Ethical Considerations

To conduct this study, approval was obtained from the Ethics Committee for Clinical Research and Animal Trials of the First Affiliated Hospital of Sun Yat-Sen University (approval number: [2023]844). Written and verbal informed consent was obtained from the participants. All data were collected anonymously and stored securely. The study was conducted in accordance with the ethical standards of the Declaration of Helsinki 2008.

Data Analysis

Descriptive, graphical, and statistical methods were employed to assess whether the scores obtained from each continuous variable followed a normal distribution. The Kolmogorov-Smirnov test was utilized to evaluate the normality of the scores derived from continuous variables using statistical methods. Categorical variables were presented as frequencies (n, %), while continuous variables were expressed as means and standard deviations. Independent samples t-tests were conducted to compare quantitative differences between independent groups. Multivariate logistic regression analysis was performed to identify independent variables associated with the dependent variable. The HosmerLemeshow test and Nagelkerke R² were used to assess the strength of the relationship between the dependent and independent variables and the goodness of fit of the regression model. Results were evaluated at a 95% confidence interval, with P-values less than 0.05 considered statistically significant. All statistical analyses were carried out using SPSS (Statistical Package for the Social Sciences) software version 26 (IBM Corp.).

Result

Description of the Sample

A total of 271 patients who underwent general anesthesia were divided into two groups based on the occurrence of postoperative sore throat: the postoperative sore throat group, with 112 cases (41.33%), and the non-postoperative sore throat group, with 159 cases (58.67%).

Univariate Analysis Findings

Univariate analysis of the impact of general and specialty conditions on the occurrence of postoperative sore throat is presented in Table 1. Age, preoperative anxiety, use of steroids, and perioperative hypothermia were found to have significant effects on the occurrence of postoperative sore throat in general anesthesia patients (P < 0.05) (Table 1).

ASA，American Society of Anesthesiologists；t，T-test ^*P＜0.05, ^**P＜0.01, ^***P＜0.001

Table 1: Univariate Analysis of Postoperative Sore Throat Occurrence in Patients under General Anesthesia. (N=271) [n(%)].

Multivariate Analysis Findings

Multiple logistic regression model analysis with the enter method was applied to determine the independent variables associated with the occurrence of postoperative sore throat (POST) by using the variables found to be statistically significant in univariate analysis results. The Hosmer and Lemes how test (χ² = 6.411, P = .601) indicated that the model was appropriate for determining the variables associated with the formation of postoperative sore throat. According to the results of the logistic regression analysis, age between 18-44 years, preoperative anxiety, and Perioperative hypothermia were identified as influencing factors for postoperative sore throat. The presence of preoperative anxiety increased the probability of developing postoperative sore throat by 2.12 times (95% CI, 1.069 to 4.205), and the occurrence of perioperative hypothermia increased the probability of postoperative sore throat by 6.769 times (95% CI, 3.585 to 12.779) (Table 2) (Figure 2).

B, regression coefficient; SE, standard error; OR, odds ratio; CI, confidence interval;

^*P＜0.05, ^**P＜0.01, ^***P＜0.001

Table 2: Multivariate Analysis of Postoperative Sore Throat Occurrence in Patients under General Anesthesia（N=271).