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Anesthesia, Essays and Researches 2022Numerous unfavorable complications may occur with strabismus surgery as emergency agitation (EA), oculocardiac reflex (OCR), postoperative pain, and postoperative nausea...
BACKGROUND
Numerous unfavorable complications may occur with strabismus surgery as emergency agitation (EA), oculocardiac reflex (OCR), postoperative pain, and postoperative nausea and vomiting (PONV).
AIMS
This study was designed to evaluate the dexmedetomidine effect in sub-Tenon's block on EA in strabismus surgery in the pediatric population under sevoflurane anesthesia.
DESIGN
This was a prospective randomized double-blind clinical trial.
PATIENTS AND METHODS
Eighty American Society of Anesthesiologists (ASA) Physical Status Class I and II pediatric patients, in an age group ranging from 2 to 8 years of either sex, had strabismus surgery under sevoflurane anesthesia using laryngeal mask airway. Patients were divided randomly into two groups (each = 40). Sub-Tenon's block is performed in the operated eye with 0.5% bupivacaine (0.08 mL.kg) alone in Group B (bupivacaine group), and with 0.5% bupivacaine (0.08 mL.kg) and dexmedetomidine (0.5 μg.kg) in Group D (dexmedetomidine group). Hemodynamics were monitored, and OCR was recorded. Furthermore, postoperative EA (Pediatric Anesthesia Emergence Delirium and Cravero Scales), pain (Face, Legs, Activity, Cry, and Consolability), and incidence of PONV were recorded as well.
STATISTICAL ANALYSIS
A prospective analysis of the collected data was performed using the SPSS program for Windows (version 26).
RESULTS
The dexmedetomidine group exhibited a lower EA incidence, pain, and PONV as compared to the bupivacaine group. No statistically significant differences regarding hemodynamics, OCR, or emergence time were found between both the groups.
CONCLUSION
The addition of dexmedetomidine to bupivacaine in sub-Tenon's block can alleviate postoperative EA and nausea and vomiting with better pain management and hemodynamic stability in pediatric strabismus surgery under sevoflurane anesthesia.
PubMed: 36249154
DOI: 10.4103/aer.aer_99_22 -
Frontiers in Pharmacology 2020Phenylephrine and atropine can cause serious adverse effects when applied in combination. We investigated the effect of phenylephrine eye drops combined with...
Phenylephrine and atropine can cause serious adverse effects when applied in combination. We investigated the effect of phenylephrine eye drops combined with intravenous atropine on the cardiovascular system in patients under general anesthesia undergoing intraocular surgery. The effects of the drugs were observed through clinical study. Thirteen patients undergoing intraocular surgery under general anesthesia were observed in this study; all were injected intravenously with atropine due to the oculocardiac reflex during surgery. To study the combination of drugs, an study was performed on rats. Seventy-two standard deviation rats that received phenylephrine eye drops and intravenous atropine treatment under general anesthesia were assessed, of which 18 treated with these drugs simultaneously were administered normal saline, neostigmine or esmolol. Blood pressure and heart rate were recorded and analyzed. The age of the patients ranged from seven to 14 years old with an average age of 10.7 years old, and 11 patients were male. In patients, 5% phenylephrine eye drops combined with intravenous atropine led to a significant heart rate increase and the increase lasted 20 min. The significant increase in diastolic blood pressure and systolic blood pressure lasted for 15 and 25 min, respectively. From five to 25 min after intravenous atropine treatment, the systolic blood pressure and diastolic blood pressure were both more than 20% higher than that at baseline. In rats, the changes in blood pressure and heart rate were independent of the phenylephrine and atropine administration sequence but were related to the administration time interval. The neostigmine group showed a significant decrease in blood pressure after the increase from the administration of phenylephrine and atropine. Phenylephrine eye drops combined with intravenous atropine have obvious cardiovascular effects that can be reversed by neostigmine. This drug combination should be used carefully for ophthalmic surgery, especially in patients with cardio-cerebrovascular diseases.
PubMed: 33584276
DOI: 10.3389/fphar.2020.596539 -
Clinical Ophthalmology (Auckland, N.Z.) 2023To better understand the sensory impact of retinal exam components typically experienced by infants undergoing various retinopathy of prematurity staging examinations,...
PURPOSE
To better understand the sensory impact of retinal exam components typically experienced by infants undergoing various retinopathy of prematurity staging examinations, adults concerned for infant welfare and exam quality underwent similar exams to compare their perceived stress.
PATIENTS AND METHODS
Adults directly involved with ROP exams and infant stress reduction had cardiac monitoring and concomitant ordinal self symptom-score (1-10 Likert) during 15 components of the exam including lid speculum, various scleral depressors, indirect ophthalmoscopy, goniolens and direct ophthalmoscopy and retinal photography (Phoenix ICON) with or without topical anesthesia.
RESULTS
Nine adults provided impressions and cardiac rhythm gathered supine over 15 minutes. Pain score for topical anesthetic 2 was less than for tropicamide 4. Lid specula numb scored a median 2 level (from 1 to 10) pain but without anesthetic scored 6. The goniolens numb scored 3. Scleral depression numb scored 3-4 but increased to 7 without topical anesthesia. Direct ophthalmoscope scored 3 through the goniolens and the retinal camera scored 4 pain. Brightness with low 350 Lux indirect scored 6-8 numb and 9 brightness without anesthetic. Full bright indirect, direct ophthalmoscope and the retinal camera all had Lux of 3000-4000 and were scored brightness 9, 7 and 10, respectively. Adults had minimal oculocardiac reflex during on-globe retinal examination methods (range 98% to 102%).
CONCLUSION
Topical anesthesia provided a moderate reduction in pain during on-globe lid-speculum, scleral depressed indirect examination. There was a synergistic augmented sensory response between pain and brightness. Adults did not show the bradycardia typically elicited by retinal examinations in premature infants.
PubMed: 37465272
DOI: 10.2147/OPTH.S418150 -
Ophthalmic Plastic and Reconstructive...To report adult patients with an orbital trapdoor fracture with extraocular muscle entrapment.
PURPOSE
To report adult patients with an orbital trapdoor fracture with extraocular muscle entrapment.
METHODS
We retrospectively reviewed 566 adult patients (>18 years) with a pure orbital fracture who were referred to us from January 2016 to May 2023. The following data were collected: age, sex, affected side, causes of injury, concomitant ocular injury and nasal bone fracture, presence or absence of oculocardiac reflex and infraorbital nerve hypesthesia, period from injury to surgery, follow-up period, and pre- and postoperative limitation of extraocular muscle motility and fields of a binocular single vision.
RESULTS
We found 5 patients (0.9%) with an orbital trapdoor fracture with extraocular muscle entrapment (age range, 19-47 years; all males; 2 right and 3 left). Causes of injury included performing a bench press, fall, assault, boxing, and bicycle accident. Entrapment of the inferior and medial recti muscles was seen in 2 and 3 patients, respectively. None of the patients had any sign of oculocardiac reflex. After surgical reduction, the field of binocular single vision became normal in 3 patients and was incompletely recovered in 2 patients, in whom consultation with us was delayed.
CONCLUSION
Adults with extraocular muscle entrapment may not present with an oculocardiac reflex. Urgent release of an entrapped muscle is, however, still recommended to avoid permanent limitation of extraocular muscle motility.
Topics: Male; Adult; Humans; Young Adult; Middle Aged; Oculomotor Muscles; Orbital Fractures; Retrospective Studies; Eye Injuries; Accidental Falls
PubMed: 38241620
DOI: 10.1097/IOP.0000000000002508 -
The Journal of Craniofacial Surgery Oct 2018Delayed repair of orbital trapdoor fractures can jeopardize the viability of entrapped contents and prolong recovery. Variation in presentations, both clinically and...
Delayed repair of orbital trapdoor fractures can jeopardize the viability of entrapped contents and prolong recovery. Variation in presentations, both clinically and radiographically, complicate prompt diagnosis. The oculocardiac reflex may be the only indication of fracture with entrapped orbital contents, but, unfortunately, the reflex has variable onset patterns and can mimic common diagnoses. Therefore, the authors present the case of a 14-year-old male with a right orbital floor fracture, who presented with delayed symptoms secondary to an oculocardiac reflex. The vagal sequelae of the reflex, including gastric hyperactivity and headache, were experienced approximately 1 week after the injury and caused the patient to be misdiagnosed with gastroenteritis and status migrainosus, on 2 separate hospital visits. After admission to the hospital due to progressive symptoms, a CT scan showed concerns for a subacute orbital blowout fracture. The patient underwent orbital floor exploration with findings of scarred orbital fat herniating into a healing fracture site. Repositioning of the fat into the orbit resulted in immediate resolution of the patient's symptoms. Awareness of the presenting characteristics of the oculocardiac reflex can lead to prompt diagnosis and maximize clinical outcomes.
Topics: Adolescent; Diagnostic Errors; Headache; Heart Rate; Humans; Male; Orbital Fractures; Reflex, Oculocardiac; Stomach Diseases; Tomography, X-Ray Computed
PubMed: 30192295
DOI: 10.1097/SCS.0000000000004966 -
The Journal of Craniofacial Surgery Oct 2022White-eyed orbital blowout fractures in the pediatric population can present with acute onset diplopia, ophthalmalgia, and abnormal duction. These findings are...
White-eyed orbital blowout fractures in the pediatric population can present with acute onset diplopia, ophthalmalgia, and abnormal duction. These findings are attributed to the tendency of younger bone to break and reapproximate owing to greater elasticity. This phenomenon, commonly referred to as the greenstick fracture, increases the risk of entrapment of surrounding soft tissue structures in orbital floor fractures. Further concern arises in the presence of an oculocardiac reflex, which requires urgent intervention to prevent serious bradycardia. Prolonged entrapment can go unnoticed and result in irreversible ischemic damage to entrapped tissues. This case discusses the presentation 16-year-old female who sustained a left sided, white-eyed blowout fracture from a face-first ground level fall. On admission, she displayed restrictive strabismus and mild periorbital edema around the left eye. Vertical gaze was restricted when looking inferiorly on the affected side. With sustained upward gaze, her heart rate decreased from 99 to 81 beats per minute. High-resolution non-contrast computed tomography scans of the head showed entrapment of the inferior rectus muscle and periorbital fat. Liberation of entrapped tissues with reduction of bony segments was performed urgently, utilizing a MEDPOR® Titan 3D orbital floor plate and secured with two screws. The patient had an uneventful postoperative period and showed considerable improvements in periorbital edema, duction, and ophthalmalgia on the affected side. In addition, the oculocardiac reflex could no longer be elicited on prolonged upward gaze. Mild and improving paresthesia was noted in the maxillary distribution of the left trigeminal nerve. Sensory deficits like this are the result of fracture communication with the infraorbital canal, which may cause irritation of the infraorbital nerve responsible for sensation by the maxillary division. By postoperative week 7, she had complete resolution of periorbital edema, indiscernible duction abnormalities, and complete healing of surgical incision sites, and an oculocardiac reflex could not be elicited.
Topics: Adolescent; Child; Diplopia; Edema; Female; Humans; Orbit; Orbital Fractures; Reflex, Oculocardiac
PubMed: 36109010
DOI: 10.1097/SCS.0000000000008713 -
Paediatric Anaesthesia Oct 2020Anesthesia providers are familiar with the oculocardiac reflex, one type of trigeminocardiac reflex. While less common, arrhythmias associated with manipulation of other...
Anesthesia providers are familiar with the oculocardiac reflex, one type of trigeminocardiac reflex. While less common, arrhythmias associated with manipulation of other trigeminal nerve branches can occur. We report the presentation and management of bradycardia and asystole from stimulation of the mandibular branch of the trigeminal nerve during temporomandibular joint reconstruction.
Topics: Bradycardia; Heart Arrest; Humans; Reflex; Reflex, Oculocardiac; Temporomandibular Joint; Trigeminal Nerve
PubMed: 32741014
DOI: 10.1111/pan.13984 -
Acta Ophthalmologica Jun 2022To evaluate the tolerability and usability of topical anaesthesia in single rectus muscle recession for strabismus caused by Graves' orbitopathy (GO). To compare the...
PURPOSE
To evaluate the tolerability and usability of topical anaesthesia in single rectus muscle recession for strabismus caused by Graves' orbitopathy (GO). To compare the perioperative pain score and surgical outcome between GO patients and non-GO patients.
METHODS
A retrospective comparative study of consecutive single rectus muscle recession performed under topical anaesthesia was carried out. All patients scheduled for one-stage single rectus muscle recession under topical anaesthesia were included. Numerical visual analogue pain score scale (NVAS) points, rates of motor success (horizontal deviation < 8 prism diopters (PD) and vertical deviation ≤ 6 PD) and sensory success (no diplopia without prisms), complications and postoperative adjustment frequencies were compared between GO and non-GO patients.
RESULTS
A total of 111 patients were included. The mean perioperative pain scores were 2.3 (SD ± 1.3) in GO and 1.6 (SD ± 1.1) in non-GO patients (p = 0.06 adjusted for gender). The postoperative mean alignments in GO and non-GO patients were 2 versus 3 PD horizontally and 1 versus 1 PD vertically respectively. Both motor and sensory success rates were 98% in GO patients and 94% versus 93% in non-GO patients. Adjustments as a second procedure the day after surgery was performed in 10% of the GO patients and 15% of the non-GO patients. The oculocardiac reflex was not triggered in any of the GO patients.
CONCLUSION
Topical anaesthesia in single muscle recession for GO is safe, well-tolerated and gives comparable surgical outcomes to those achieved in non-GO patients.
Topics: Anesthesia, Local; Graves Ophthalmopathy; Humans; Oculomotor Muscles; Ophthalmologic Surgical Procedures; Pain; Retrospective Studies; Strabismus; Treatment Outcome
PubMed: 34532987
DOI: 10.1111/aos.15024 -
Journal of Maxillofacial and Oral... Jun 2015To study effects of zygomatico maxillary fractures and fracture reduction on intra ocular pressure (IOP).
PURPOSE
To study effects of zygomatico maxillary fractures and fracture reduction on intra ocular pressure (IOP).
MATERIALS AND METHODS
IOPs of 20 patients with unilateral zygomatico-maxillary complex (ZMC) fractures (divided into 2 groups of 10 undisplaced, 10 displaced) were measured at various time intervals. The relationship between IOPs between the two groups at various time intervals was recorded and evaluated using independent T-tests.
RESULTS
20 subjects were divided into two equal groups (10 each of displaced and undisplaced fractures). Mean age of patients was 33.8 years with 90 % males and 10 % females. The change in IOP at the time of reporting, after 24 h and 7 days for patients with undisplaced ZMC fractures (Group I) was recorded and was found to be significant. The change in IOP at the time of reporting, before and after surgery, after 24 h and 7 days for patients with displaced ZMC fractures (Group II) was recorded and was also found to be significant. The IOPs of the two groups was compared at various time intervals and was found to be significant. Also, a significant increase in IOP was noted just after fracture reduction, which could be attributed to oculocardiac reflex, which has been proven to cause bradycardia, and in some cases, even death.
CONCLUSION
A cautious eye needs to be kept over IOP while reducing ZMC fractures at regular intervals and the anaesthetist has to be informed to look for any bradycardia that can occur. Tonometers should be a part of standard armamentarium while reducing and fixing ZMC fractures.
PubMed: 26028839
DOI: 10.1007/s12663-013-0614-4 -
Medicine May 2021Intravenous dexmedetomidine (DEX) has been used to prevent emergence agitation (EA) in children. The aim of this meta-analysis was to evaluate whether DEX decreases EA... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Intravenous dexmedetomidine (DEX) has been used to prevent emergence agitation (EA) in children. The aim of this meta-analysis was to evaluate whether DEX decreases EA incidence without augmenting oculocardiac reflex (OCR) in pediatric patients undergoing strabismus surgery.
METHODS
We searched PubMed, EMBASE, Chinese National Knowledge Infrastructure (CNKI), Wan Fang, and the Cochrane Library to collect the randomized controlled trials (RCTs) investigating the effects of intraoperative DEX in children undergoing strabismus surgery from inception to October 2019. Postoperative Pediatric Agitation and Emergence Delirium (PAED) score, postoperative EA, extubation or laryngeal mask airway (LMA) removal time, postanesthetic care unit (PACU) stay time, OCR, and postoperative vomiting (POV) were evaluated.
RESULTS
11 RCTs including 801 patients were included in this study. Compared with control group, intravenous DEX significantly reduced postoperative PAED score (WMD, 3.05; 95% CI: -3.82 to -2.27, P = .017) and incidences of postoperative EA 69% (RR, 0.31; 95% CI: 0.17 to 0.55, P < .00) and POV (RR, 0.28; 95% CI: 0.13 to 0.61, P = .001). Furthermore, the use of DEX significantly delayed extubation or LMA removal time (WMD, 2.11; 95% CI: 0.25 to 3.97, P < .001). No significant difference was found in the incidence of ORC and PACU stay time.
CONCLUSION
Intravenous DEX reduced the incidences of EA without increasing OCR in pediatric patients undergoing strabismus surgery. Meanwhile, DEX infusion decreased the incidence of POV in children.
Topics: Anesthesia, General; Dexmedetomidine; Emergence Delirium; Humans; Incidence; Injections, Intravenous; Ophthalmologic Surgical Procedures; Perioperative Period; Randomized Controlled Trials as Topic; Reflex, Oculocardiac; Strabismus; Treatment Outcome
PubMed: 33950954
DOI: 10.1097/MD.0000000000025717