Use of Muscle Relaxants in Parotidectomy Operation With Neuromonitoring
Condition: Intubation; Difficult or Failed; Muscle Relaxation; Anesthesia Intubation Complication; Airway Complication of Anesthesia
MeSH terms: Muscle Hypotonia
Study type: Interventional

Summary: 
      Neuromuscular blockers provide muscle relaxation by blocking the electrical conduction to
      motor nerves and facilitate endotracheal tube placement while relaxing the whole body for
      surgical comfort during general anesthesia. Parotid surgery is a procedure performed by ear,
      nose and throat physicians, and as a complication during this procedure, permanent facial
      paralysis may develop due to damage to the facial nerve. Intraoperative nerve monitoring is
      frequently used to avoid this complication. The application of local anesthetic to the vocal
      cords and into the trachea has been tried and found useful for induction of anesthesia
      without the use of neuromuscular blockers. In studies conducted with this technique, a
      standard local anesthetic dose was not specified and local anesthetics were generally
      administered alone and in high doses. It is expected that anesthesia induction and intubation
      without the use of muscle relaxants will not affect the comfort of the patient and the
      procedure, but will increase the surgical time and surgical satisfaction.
    

Detailed description: 
      A general anesthesia technique is required, which will not only facilitate tracheal
      intubation during anesthesia but also minimize complications that may develop during and
      after surgery and/or anesthesia without the neuromuscular blocker effect. For this purpose;
      Induction techniques can be used without the use of muscle relaxants, which will affect the
      hemodynamic response less. By applying muscle relaxants, its effect can be expected to
      disappear completely during surgery, or muscle relaxants such as succinylcholine, which are
      very short-acting, can be used. However, the use of succinylcholine has almost ceased to be
      used clinically due to anaphylaxis, severe post-operative muscle pain, increased serum
      potassium levels, rarely prolonged effects, and other cardiovascular side effects that may
      develop. Sugammadex, which has recently entered clinical use, can be used to reverse the
      effect of muscle relaxants. After induction, it is necessary to use high doses of sugammadex
      to immediately reverse the muscle relaxant effect. Waiting for the effects of muscle
      relaxants to pass, especially in surgical procedures that require neuromonitoring, prolongs
      the surgical time. This again leads to high costs. The application of local anesthetic to the
      vocal cords and into the trachea has been tried and found useful for induction of anesthesia
      without the use of neuromuscular blockers. In studies conducted with this technique, a
      standard local anesthetic dose was not specified and local anesthetics were generally
      administered alone and in high doses. Therefore, local anesthetic administered together with
      the inhalation agent during induction may provide better comfort during tracheal intubation.
      It is expected that anesthesia induction and intubation without the use of muscle relaxants
      will not affect the comfort of the patient and the procedure, but will increase the surgical
      time and surgical satisfaction.
    

Intervention name(s): Group A - Muscle Relaxants Used; Group B - No Muscle Relaxants
Intervention type(s): Procedure; Procedure
Intervention description(s): Induction will be achieved with 1 mg/kg lidocaine, 2 μg/kg fentanyl, 2 mg/kg propofol, and 0.6 mg/kg rocuronium stored at 4 degrees. After the induction, laryngoscopy will be performed with a Macintosh laryngoscope after 2 minutes of manual ventilation after muscle relaxant by an anesthesiologist with at least 4 years of experience. It will be intubated with a tube with an inner diameter of 8 mm for men and 7 mm for women. The cuff of the intubation tube will be connected to a manometer and inflated at a pressure of 20-30 mmHg until there is no air leak. Intubation will be confirmed by the appearance of end-tidal CO2.; Induction will be provided with 1 mg/kg lidocaine, 2 μg/kg fentanyl, 2 mg/kg propofol. After ventilation, vocal cords will be seen with a Macintosh laryngoscope, and 2cc of 2% lidocaine will be applied to the vocal cords as a spray with the help of a 5 ml injector. After ventilation, laryngoscopy will be performed with a Macintosh laryngoscope by an anesthesiologist with at least 4 years of experience. It will be intubated with a tube with an inner diameter of 8 mm for men and 7 mm for women. The cuff of the intubation tube will be connected to a manometer and inflated at a pressure of 20-30 mmHg until there is no air leak. Intubation will be confirmed by the appearance of end-tidal CO2.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Participant)
Primary purpose: Screening
Keywords: parotid surgery; muscle relaxants; airway management; neuromonitoring