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Clinical Ophthalmology (Auckland, N.Z.) 2021The oculocardiac reflex (OCR) is a sudden vagal bradycardia that can be elicited by traction on an extraocular muscle. Bradycardia is highly variable from case to case...
BACKGROUND
The oculocardiac reflex (OCR) is a sudden vagal bradycardia that can be elicited by traction on an extraocular muscle. Bradycardia is highly variable from case to case necessitating a large sample size to observe small to moderate impact on OCR. While the surgeon's tissue manipulation has immediate impact on OCR and individual patients may have some proclivity to OCR, we sought to characterize the impact on OCR by the anesthesiologist.
METHODS
From 1992 to 2019, during routine, community outpatient general anesthetic strabismus surgery, oculocardiac reflex was prospectively observed utilizing a uniform 10-second, 200 gram square wave tension on each extraocular muscle. Anesthetic parameters were recorded and analyzed with double-cohort design and non-parametric statistics and correlations. We define %OCR as the maximally tension-altered heart rate and a percent of stable pre-tension heart rate.
RESULTS
The median (IQR) confidence intervals OCR for 2527 initial cases was 89% (67% to 97%) without anticholinergic, and 99% (95% to 100%) in 165 patients with anticholinergic. OCR was 81% (62% to 96%) in 1034 with opioids and to 75% (60% to 95%) in 59 with dexmedetomidine and in 189 with IV dexamethasone to 72% (56% to 92%) There was a significant (p<0.01 Kruskal-Wallis) impact on OCR by various opioids, muscle relaxants and inhalational agents. Linear regression showed significant inhibitory impact on OCR by increased inhalational agent depth and by lower exhaled CO.
CONCLUSION
The anesthesiologist can block OCR with sufficient anticholinergics, deeper inhalational agents and robust ventilation, and can augment OCR with opioids, dexmedetomidine and apparently also with dexamethasone.
CLINICAL TRIALS REGISTRY
NCT04353960.
PubMed: 33716499
DOI: 10.2147/OPTH.S300860 -
Journal of Maxillofacial and Oral... Mar 2022Trapdoor fractures commonly occur in children below 6 years of age. The high resiliency of bone, pneumatisation of sinuses and other factors lead to entrapment of... (Review)
Review
BACKGROUND
Trapdoor fractures commonly occur in children below 6 years of age. The high resiliency of bone, pneumatisation of sinuses and other factors lead to entrapment of muscle and/or soft tissue which undergoes ischaemic changes leading to residual diplopia. The timing of intervention in children ranges from 24 h to greater than 2 weeks. Early surgical intervention is particularly indicated in cases of Oculocardiac reflex.
METHODS
A Prisma guided systematic review of literature was conducted with no filters on language till September 2020. Studies on paediatric orbital fractures with data on timing of intervention and clinical outcomes were considered eligible for the review. The Oxford Level Of Evidence was used to assess the strength of individual studies.
RESULTS
A total of 19 studies (18 English, 1 French) were selected; except for one study all were retrospective series. The timing of intervention ranged from 24 h to more than 1 month. Most of the studies agreed that orbital fractures in children should receive early intervention preferably within 2 weeks. In case of white-eyed blowout fracture, oculocardiac reflex and trapdoor fractures with muscle entrapment surgical intervention should be carried out within 24-48 h.
DISCUSSION
Children presenting with facial injuries should be thoroughly examined for signs of muscle entrapment, diplopia, nausea, vomiting and bradycardia. If present these should receive early intervention. In cases with no signs of oculocardiac reflex and muscle entrapment a treatment within 2 weeks is recommended. If diplopia is mild or resolving with minimal hypoglobus and enophthalmos a wait and watch policy should be carried out.
PubMed: 35400913
DOI: 10.1007/s12663-021-01543-y -
Journal of AAPOS : the Official... Jun 2018We reported that premedication with nasal dexmedetomidine was associated with a more intense oculocardiac reflex (OCR). In this study we performed an intrasubject,... (Comparative Study)
Comparative Study
BACKGROUND
We reported that premedication with nasal dexmedetomidine was associated with a more intense oculocardiac reflex (OCR). In this study we performed an intrasubject, intravenous comparison to test our hypothesis that this alpha-adrenergic agonist potentiates the trigemino-vagal reflex.
METHODS
OCR (greatest change heart rate/baseline heart rate) was prospectively monitored with 10-second, square-wave 200 g tension on the inferior rectus or other muscles during strabismus surgery. Between the first and second muscle, intravenous dexmedetomidine 0.5 μg/kg was delivered.
RESULTS
All patients had no anticholinergic agents. A total 842 historic control patients (median age, 5.5 years) with no dexmedetomidine between muscles experienced the first OCR of 75% ± 24% (SD) and the second OCR of 77% ± 22%. The 33 study patients (median age, 5.6 years) experienced the first OCR 84% ± 16% and dexmedetomidine second OCR of 66% ± 25% for a bradycardia augmentation of 18% ± 19% (P < 0.01 [Mann-Whitney]).
CONCLUSIONS
Similar to the effect of fentanyl, intravenous fast-push dexmedetomidine augmented the bradycardia associated with extraocular muscle traction.
Topics: Adrenergic alpha-2 Receptor Agonists; Anesthetics, Inhalation; Child; Child, Preschool; Dexmedetomidine; Electrocardiography; Female; Heart Rate; Humans; Injections, Intravenous; Male; Oculomotor Muscles; Ophthalmologic Surgical Procedures; Reflex, Oculocardiac; Sevoflurane; Strabismus
PubMed: 29733898
DOI: 10.1016/j.jaapos.2018.01.016 -
BMC Anesthesiology Jul 2023Dexmedetomidine is a medication that has analgesic, sedative, and anti-anxiety properties. In the clinical, it is often used to prevent common complications associated... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
Dexmedetomidine is a medication that has analgesic, sedative, and anti-anxiety properties. In the clinical, it is often used to prevent common complications associated with strabismus surgery, including postoperative delirium, postoperative nausea and vomiting, postoperative pain, and oculocardiac reflex. However, its effectiveness and side effects of the present studies are different. The sample sizes of the present studies on the prevention of complications of dexmedetomidine are small. Therefore, this study evaluates the efficacy of dexmedetomidine in preventing anesthesia-related complications in strabismus surgery through a systematic review and meta-analysis.
METHODS
Literature was retrieved from 10 commonly used databases and randomized controlled trials published up to May 2022 were sought. The included studies compared the intervention effects of dexmedetomidine versus placebo on anesthesia-related complications in surgery. The occurrence rates of postoperative delirium, postoperative nausea and vomiting, postoperative pain, and oculocardiac reflex in patients undergoing strabismus surgery were evaluated. Statistical analyses and forest plots were generated using Review Manager and STATA software. Binary outcomes were measured using relative risk (RR) with a 95% confidence interval for each outcome. The Cochrane risk of bias tool was used to assess the bias and risk in the studies that met the inclusion criteria.
RESULTS
A total of 13 articles were ultimately included in the analysis, comprising 1,018 patients who underwent strabismus surgery. The dexmedetomidine group, compared to the placebo group, demonstrated significant reductions in the incidence of postoperative delirium (RR = 0.73, P = 0.001), severe postoperative delirium (RR = 0.45, P = 0.005), postoperative nausea and vomiting (RR = 0.48, P < 0.0001), and the need for supplemental analgesia postoperatively (RR = 0.60, P = 0.004). Additionally, subgroup analysis revealed that intravenous administration of dexmedetomidine significantly reduced the incidence of oculocardiac reflex (RR = 0.50, P = 0.001). In contrast, intranasal administration of dexmedetomidine did not have a significant effect on the incidence of oculocardiac reflex (RR = 1.22, P = 0.15). There was a significant difference between the subgroups (P = 0.0005, I2 = 91.7%).
CONCLUSION
Among patients undergoing strabismus surgery, the use of dexmedetomidine can alleviate postoperative delirium and reduce the incidence of postoperative nausea and vomiting, as well as postoperative pain. Moreover, intravenous administration of dexmedetomidine can lower the occurrence rate of the oculocardiac reflex.
Topics: Humans; Postoperative Nausea and Vomiting; Dexmedetomidine; Emergence Delirium; Pain, Postoperative; Strabismus; Anesthesia
PubMed: 37491215
DOI: 10.1186/s12871-023-02215-9 -
PloS One 2018This study aimed to examine the incidence of the oculocardiac reflex during a non-invasive intracranial pressure measurement when gradual external pressure was applied...
PURPOSE
This study aimed to examine the incidence of the oculocardiac reflex during a non-invasive intracranial pressure measurement when gradual external pressure was applied to the orbital tissues and eye.
METHODS
Patients (n = 101) and healthy volunteers (n = 56) aged 20-75 years who underwent a non-invasive intracranial pressure measurement were included in this retrospective oculocardiac reflex analysis. Prespecified thresholds greater than a 10% or 20% decrease in the heart rate from baseline were used to determine the incidence of the oculocardiac reflex.
RESULTS
None of the subjects had a greater than 20% decrease in heart rate from baseline. Four subjects had a greater than 10% decrease in heart rate from baseline, representing 0.9% of the total pressure steps. Three of these subjects were healthy volunteers, and one was a glaucoma patient.
CONCLUSION
The incidence of the oculocardiac reflex during a non-invasive intracranial pressure measurement procedure was very low and not associated with any clinically relevant effects.
Topics: Adult; Aged; Data Interpretation, Statistical; Diagnostic Techniques and Procedures; Female; Heart Rate; Humans; Intracranial Pressure; Male; Middle Aged; Models, Statistical; Reflex, Oculocardiac; Young Adult
PubMed: 29672564
DOI: 10.1371/journal.pone.0196155 -
Journal of the American Veterinary... Apr 2022To evaluate neurological tests and expected results in inland bearded dragons (Pogona vitticeps) and generate recommendations for bearded dragon-specific neurological...
OBJECTIVE
To evaluate neurological tests and expected results in inland bearded dragons (Pogona vitticeps) and generate recommendations for bearded dragon-specific neurological examination.
ANIMALS
26 healthy adult inland bearded dragons.
PROCEDURES
A complete neurological examination utilizing tests described in both mammals and reptiles was performed on each lizard, and test feasibility and outcome were recorded.
RESULTS
Tests with poor feasibility included oculocardiac reflex (successfully completed in 62% [16/26] of animals) and voluntary ambulation and swallowing by use of a food item (0% [0/26] of animals). Tests with outcomes considered abnormal in mammals but attributable to normal bearded dragon behavior included head position (head tilt present in 12% [3/26]) and head movement (head bob present in 4% [1/26]). Many tests had absent or inconsistent outcomes, including menace response (present in 19% [5/26]), proprioceptive positioning (present in 4% [1/26] in the thoracic limbs and 0% [0/26] in the pelvic limbs), vent reflex (present in 27% [7/26]), and myotatic reflexes (biceps present in 8% [2/26]; patellar, gastrocnemius, and triceps present in 0% [0/26]). Extensor postural thrust was absent in all successfully tested animals, but a novel reflex termed the caudal thoracic extensor reflex was noted instead in all observed animals (100% [21/21]).
CLINICAL RELEVANCE
Tests with poor feasibility or inconsistent outcomes should have low priority or be excluded from neurological examinations of inland bearded dragons. Normal behaviors should be considered for head position and movement. A bearded dragon-specific neurological examination protocol derived from these findings is described and recommended in order to decrease stress and improve neurolocalization.
Topics: Animals; Lizards; Mammals; Neurologic Examination
PubMed: 35417409
DOI: 10.2460/javma.20.12.0706 -
The Impact of Re-Operation, Relatives and Race on the Oculocardiac Reflex During Strabismus Surgery.Clinical Ophthalmology (Auckland, N.Z.) 2020The oculocardiac reflex (OCR) is a trigeminovagal bradycardia elicited by tension on an extraocular muscle (EOM). Using three decades of observational data, we...
PURPOSE
The oculocardiac reflex (OCR) is a trigeminovagal bradycardia elicited by tension on an extraocular muscle (EOM). Using three decades of observational data, we investigated whether or not individual strabismus patients are prone to oculocardiac reflex.
PATIENTS AND METHODS
All patients undergoing strabismus surgery from 1992 to 2019 had deliberate 10-second, 200-gram square-wave tension on extraocular rectus muscles with anesthetic variables recorded. OCR was defined as the maximally tension-altered heart rate as a percent of stable baseline heart rate.
RESULTS
OCR was compared in 2532 original cases with 323 re-operations. The 169 cases that used anticholinergics (99% OCR) were excluded from the analysis. The median OCR, a 15% drop, was found to be 85% (95% CI 39%, 102%,; range 5-151%). Factors that showed a significant effect on the OCR were the type of EOM with lateral rectus least (Kruskal-Wallis X(3)=8, p<0.05), and adults had less OCR compared to the children (X(2)=105, p<0.01). Factors that showed an augmenting effect on the OCR were peri-operative opioids (X(6)=62, p<0.01) and Caucasian race (X(4)=12, p<0.02). Gender and iris color were not found to have an impact on OCR. Re-operations and first-degree relatives did not differ from age-matched controls, but EOM- and opioid-adjusted re-operations correlated with their initial cases (r=0.37).
CONCLUSION
We confirmed the previously published blocking effect of atropine, augmenting impact of opioids, and an inverse relationship of age on OCR. There was a weak proclivity for individuals to be prone to OCR. We found an impact of race with Caucasians having more OCR.
PubMed: 33299298
DOI: 10.2147/OPTH.S288578 -
Brazilian Journal of Anesthesiology... 2021The most common cause of oculocardiac reflex (OCR) is traction of the extraocular muscles. Therefore, strabismus surgery is highly risk for the development of this... (Observational Study)
Observational Study
BACKGROUND AND OBJECTIVES
The most common cause of oculocardiac reflex (OCR) is traction of the extraocular muscles. Therefore, strabismus surgery is highly risk for the development of this complication. This study aimed to investigate whether an association exists between the occurrence of OCR and the type of extraocular muscle manipulated during strabismus in a pediatric population.
METHODS
A total of 53 pediatric patients who were operated for strabismus under sevoflurane anesthesia were enrolled in this prospective study. The association between surgical techniques and the occurrence of OCR was investigated.
RESULTS
This study included 30 (56.6%) males and 23 (43.4%) females, with a mean age of 8.4 years. Overall, 83 eyes with 93 extraocular muscles were operated. Surgery was performed most frequently on the medial (44.6%) and lateral (36.1%) recti. OCR occurred in 33 (62.3%) patients. OCR was found to be significantly higher in the first operated muscle compared with the second muscle, regardless of muscle type, as identified in the statistical analysis based on the sequence of the operated muscles.
CONCLUSIONS
The manipulation of the first extraocular muscle has a higher risk of OCR in the pediatric population undergoing two-muscle surgery for strabismus.
Topics: Child; Female; Humans; Male; Oculomotor Muscles; Prospective Studies; Reflex, Oculocardiac; Sevoflurane; Strabismus
PubMed: 34715994
DOI: 10.1016/j.bjane.2020.12.015 -
Journal of AAPOS : the Official... Feb 2019
Topics: Dexmedetomidine; Humans; Oculomotor Muscles; Reflex, Oculocardiac; Strabismus
PubMed: 30253240
DOI: 10.1016/j.jaapos.2018.09.001 -
European Journal of Ophthalmology Nov 2019To date, no protocol of anesthesia for pediatric ophthalmic surgery is unanimously recognized. The primary anesthetic risks are associated with strabismus surgery,...
PURPOSE
To date, no protocol of anesthesia for pediatric ophthalmic surgery is unanimously recognized. The primary anesthetic risks are associated with strabismus surgery, including oculocardiac reflex, postoperative nausea and vomiting, and postoperative pain.
METHODS
This was a prospective, monocentric, observational study conducted in a tertiary pediatric ophthalmic unit. Our anesthetic protocol for strabismus surgery included postoperative nausea and vomiting prevention using dexamethasone and ondansetron. No drug-based prevention of oculocardiac reflex or local/locoregional anesthesia was employed.
RESULTS
A total of 106 pediatric ophthalmic surgeries completed between November 2015 and May 2016 were analyzed. The mean patient age was 4.4 (range: 0.2-7.3, standard deviation: 2.4) years. Ambulatory rate was 90%. Oculocardiac reflex incidence was 65% during strabismus surgery (34/52), 50% during congenital cataract surgery (4/8), 33% during intramuscular injection of botulinum toxin (1/3), and 0% during other procedures. No asystole occurred. Postoperative nausea and vomiting incidence was 9.6% after strabismus surgery (5/52) and 0% following the other procedures. One child was hospitalized for one night because of persistent postoperative nausea and vomiting. Postoperative pain generally occurred early on in the recovery room and was quickly controlled. Its incidence was higher in patients who underwent strabismus surgery (27%) than in those who underwent other procedures (9%).
CONCLUSION
Morbidity associated with ophthalmic pediatric surgery is low and predominantly associated with strabismus surgery. The benefit-risk ratio and cost-effectiveness of oculocardiac reflex prevention should be questioned. Our postoperative nausea and vomiting rate is low, thanks to the use of a well-managed multimodal strategy. Early postoperative pain is usually well-treated but could probably be more effectively prevented.
Topics: Acetaminophen; Anesthesia, Local; Anesthetics, Combined; Anesthetics, Intravenous; Anti-Anxiety Agents; Cataract; Child; Child, Preschool; Dexamethasone; Female; Glucocorticoids; Humans; Infant; Male; Midazolam; Ondansetron; Ophthalmologic Surgical Procedures; Pain, Postoperative; Postoperative Nausea and Vomiting; Propofol; Prospective Studies; Reflex, Oculocardiac; Strabismus; Vomiting
PubMed: 30280604
DOI: 10.1177/1120672118804798