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Anaesthesia, Critical Care & Pain... Apr 2021
Topics: Anesthesia; Anesthesia, Local; Anesthetics, Local; Humans; Incidence; Lidocaine; Melanoma; Pain, Postoperative; Reflex, Oculocardiac; Uveal Neoplasms
PubMed: 33753295
DOI: 10.1016/j.accpm.2021.100835 -
Indian Journal of Ophthalmology Apr 2021This study compares the vital parameters and pain experienced during phacoemulsification under peribulbar and topical anesthesia to determine the incidence of OCR. (Randomized Controlled Trial)
Randomized Controlled Trial
PURPOSE
This study compares the vital parameters and pain experienced during phacoemulsification under peribulbar and topical anesthesia to determine the incidence of OCR.
METHODS
One hundred six patients are enrolled for phacoemulsification in a prospective and randomized study. Fifty-two patients undergo surgery in a peribulbar block (Group PB) and 54 in topical anesthesia (Group TA). Mean arterial pressure (MAP) and pulse rate are recorded during a preoperative check-up and at four other steps of surgery. Pain experienced during surgery and on a postoperative day, 5, is graded with a verbal analogue scale. OCR defined as a decrease in pulse rate by greater than 20% is calculated. Chi-square test, Fisher's exact test, paired t test and the comparison of means give the statistical analysis. A value of P < 0.05 was taken as significant.
RESULTS
MAP readings at baseline versus MAP at other steps of surgery show a trend towards rising with a P value of < 0.05 in both groups. Pulse rate measured at all steps of surgery versus baseline pulse rate in Group TA shows P < 0.05. OCR is present in nine patients in peribulbar block verses eleven patients in topical anesthesia with P value of 0.687. The pain scores using verbal analogue scale were higher in Group TA compared with Group PB with a P < 0.0001.
CONCLUSION
Oculocardiac reflex can occur during phacoemulsification under both peribulbar block and topical anesthesia, and the difference is not significant.
Topics: Administration, Topical; Anesthesia, Local; Anesthetics, Local; Humans; Lidocaine; Pain Measurement; Pain, Postoperative; Phacoemulsification; Prospective Studies; Reflex, Oculocardiac
PubMed: 33727460
DOI: 10.4103/ijo.IJO_1019_20 -
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 Cranio-maxillo-facial... May 2021The study aimed to correlate between the stimulated nerve, intensity of trigeminovagal reflex (TVR), and neuropathophysiological pathway by which the efferent arc is...
The trigeminocardiac reflex: Does the activation pathway of its efferent arc affect the intensity of the hemodynamic drop during the management of maxillofacial fractures?
The study aimed to correlate between the stimulated nerve, intensity of trigeminovagal reflex (TVR), and neuropathophysiological pathway by which the efferent arc is activated. Material and methods: A retrospective study included patients who developed TVR during the surgical management of mandibular, midface, and orbital fractures. The reflex was divided into type I, II, III, and IV-TVR according to the following nerves: ophthalmic, maxillary, mandibular, and non-trigeminal nerves, respectively. The magnitude of hemodynamic drops was identified at the intraoperative baseline, during reflex, and postoperatively. The needed time to elicit the reflex, frequency and duration, need for medical intervention, and sequence of the drop were also recorded. P - values < 0.05 was considered significant. Out of 260 patients' files were reviewed, the TVR was observed in only 30 (11.55 %) patients. The ophthalmic nerve activation significantly caused the greatest intensity and magnitude of hemodynamic drop, followed by maxillary nerve, then mandibular division, and the lowest one was non-trigeminal nerves. The highest mean of drops in the mean arterial blood pressure (MABP) was 62.92 ± 2.39 with the type ITVR, whereas those of the type II, III, and IV were 75.5 ±3.98, 81.02±1.31, and 82.22±1.85, respectively. Also, the type I-TVR led to the greatest decrease in the heart rate (HR) with the mean equaled to 52.31± 3.91. The drop percentage in the MABP was -30.5, -17.5, -12, -10.08 for type I, II, III, and IV, whereas those of the HR were - 33.9, -27.13, -26.6, and -25 with type I, II, III, and IV, respectively. All results showed highly significant differences with p-values less than 0.001 when comparing between the baseline and intraoperative values of each TVR type. There is a positive correlation between the activated pathway of the TVR and the intensity of its efferent arc response due to the neural pathway of each division in the brainstem circuitry. Understanding of the pathophysiology and mechanism of the TVR, together with the rapid recognition and treatment could prevent serious negative outcomes, especially when the ophthalmic nerve is stimulated. 1Introduction.
Topics: Humans; Mandible; Reflex; Reflex, Trigeminocardiac; Retrospective Studies; Trigeminal Nerve
PubMed: 33632536
DOI: 10.1016/j.jcms.2021.02.004 -
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 -
BMC Anesthesiology Feb 2021Postoperative nausea and vomiting (PONV) is one of the most frequent complications following strabismus surgery. Penehyclidine, an anticholinergic agent, is widely used... (Randomized Controlled Trial)
Randomized Controlled Trial
Penehyclidine mitigates postoperative nausea and vomiting and intraoperative oculocardiac reflex in patients undergoing strabismus surgery: a prospective, randomized, double-blind comparison.
BACKGROUND
Postoperative nausea and vomiting (PONV) is one of the most frequent complications following strabismus surgery. Penehyclidine, an anticholinergic agent, is widely used as premedication. This study investigated the effect of preoperative penehyclidine on PONV in patients undergoing strabismus surgery.
METHODS
In this prospective, randomized, double-blind study, patients scheduled for strabismus surgery under general anesthesia were randomly assigned to either penehyclidine (n = 114) or normal saline (n = 104) group. Penehyclidine was administrated immediately after anesthesia induction, and normal saline was substituted as control. PONV was investigated from 0 to 48 h after surgery. Intraoperative oculocardiac reflex (OCR) was also recorded.
RESULTS
Compared with normal saline, penehyclidine significantly reduced PONV incidence (30.7% vs. 54.8%, P < 0.01) and mitigated PONV severity as indicated by severity scoring (P < 0.01). Compared with normal saline, penehyclidine also significantly reduced OCR incidence (57.9% vs. 77.9%, P < 0.01) and mitigated OCR severity, as indicated by the requirement for atropine rescue (77.3% vs. 90.1%, P < 0.05) and the maximum decrease of heart rate during OCR (23.1 ± 9.4 bpm vs. 27.3 ± 12.4 bpm, P < 0.05). The recovery course did not differ between groups.
CONCLUSIONS
Penehyclidine administrated after anesthesia induction significantly reduced the incidence of PONV and alleviated intraoperative OCR in patients undergoing strabismus surgery.
TRIAL REGISTRATION
ClinicalTrials.gov ( NCT04054479 ). Retrospectively registered August 13, 2019.
Topics: Adolescent; Adult; Aged; Child; Child, Preschool; Double-Blind Method; Female; Humans; Intraoperative Complications; Male; Middle Aged; Postoperative Nausea and Vomiting; Quinuclidines; Reflex, Oculocardiac; Strabismus; Young Adult
PubMed: 33581727
DOI: 10.1186/s12871-021-01266-0 -
Journal of the Korean Association of... Dec 2020Orbital floor blowout fractures can result in a variety of signs and symptoms depending on the severity of the bone defect. Large defects often result in enophthalmos...
Orbital floor blowout fractures can result in a variety of signs and symptoms depending on the severity of the bone defect. Large defects often result in enophthalmos and restriction of ocular movement; yet the timing of surgery can be delayed up to two weeks with good functional outcomes. In contrast, an orbital trapdoor defect with entrapment of the inferior rectus muscle usually elicits pain with marked restriction of the upward gaze and activation of the oculocardiac reflex without significant dystopia or enophthalmos. When autonomic cardiac derangement is diagnosed along with an orbital floor fracture, it has been suggested that the fracture should be treated immediately. Otherwise, it will result in continued hemodynamic instability and muscular injury and may require a second surgery. This article reports the management of an unusual presentation of a trapdoor blowout orbital floor fracture surgery with oculocardiac response in an adult, with emphasis on its pathophysiology, management, and differential diagnosis.
PubMed: 33377469
DOI: 10.5125/jkaoms.2020.46.6.428 -
Clinical Ophthalmology (Auckland, N.Z.) 2020Reducing physiologic stress including bradycardia during staging eye exams for retinopathy of prematurity (ROP) is desirable. We observed heart rate change during...
PURPOSE
Reducing physiologic stress including bradycardia during staging eye exams for retinopathy of prematurity (ROP) is desirable. We observed heart rate change during routine retinopathy of prematurity eye examinations and compared the response with our ongoing study of oculocardiac reflex (OCR) elicited by uniform EOM tension during strabismus surgery.
PATIENTS AND METHODS
Electrocardiograph was prospectively monitored during ROP exams featuring indirect ophthalmoscopy with Alfonso lid speculum and see-through scleral depressor without topical anesthesia. Clinical data were retrieved from ROP-Check software. OCR was defined as maximally changed heart rate (HR) as a percent of baseline. Strabismus surgery patients under general anesthesia served as controls.
RESULTS
From 10/2017 to 9/2020, 281 infants had ROP exams, and the median OCR was 55.9% of baseline HR (IQR 41.4% to 72.6%), the kurtosis 0.93 and skewness 1.01 representing a drop from HR 169 ± 16 bpm to 102 ± 39 bpm. In comparison, 1493 adult and pediatric strabismus surgery patients had less OCR median bradycardia 87.8% (IQR 72-98%), kurtosis 1.60 and skewness -1.18. ROP %OCR correlated with birth gestational age (%OCR = 2.5 (GA) - 11, r(279)=0.33, p<0.01) and with birthweight (%OCR = 0.02 (BW) + 38, r(279) =0.35, p<0.01). The duration of bradycardia induced by ROP exam averaged 92 ± 34 seconds (range 34-240 seconds).
CONCLUSION
Bradycardia is common during eye exams in the smallest premature infants with greater degree, more rapid onset and longer duration than OCR during strabismus surgery.
PubMed: 33324032
DOI: 10.2147/OPTH.S288043 -
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 -
European Journal of Ophthalmology Nov 2021To evaluate the efficacy and safety of peribulbar anesthesia during strabismus surgery.
PURPOSE
To evaluate the efficacy and safety of peribulbar anesthesia during strabismus surgery.
METHODS
Medical records of patients undergoing strabismus surgery and peribulbar anesthesia were reviewed. The overall efficacy of peribulbar anesthesia was evaluated as requirement of supplemental peribulbar anesthesia, impossibility to perform eye muscles surgery due to inadequate efficacy of the block and peribulbar block complications that occurred up to 6 weeks postoperatively. Presence of oculocardiac reflex (OCR) and presence of decreased visual acuity and afferent pupillary defect postoperatively were reported.
RESULTS
A total of 510 patients comprised our study group. The total amount of peribulbar injections was 717. Four patients (0.7%) required supplemental injection in the superonasal quadrant. Five of 510 (0.9%) required an anesthesiologic intervention with intravenous atropine. Eighty patients of 510 (15.6%) complained about transitory complete ptosis and/or amaurosis postoperatively. No complications were observed up to 6 weeks postoperatively.
CONCLUSION
Peribulbar anesthesia was an effective and safe option during strabismus surgery in adult patients.
Topics: Adult; Anesthesia, Local; Anesthetics, Local; Humans; Oculomotor Muscles; Reflex, Oculocardiac; Strabismus
PubMed: 33225731
DOI: 10.1177/1120672120974947