Effects of peribulbar bupivacaine as an adjunct to general anaesthesia on peri-operative outcome following retinal detachment surgery

Sixty premedicated, ASA physical status I or II patients weighing > 25 kg scheduled for elective retinal detachment repair were randomly assigned to receive either peribulbar block with 10 ml of 0.25% bupivacaine (block group) or intravenous morphine 150 microg.kg-1 (morphine group), prior to the induction of general anaesthesia (n = 30 in each group). Patients were evaluated for intra-operative oculocardiac reflex, peri-operative pain relief, recovery from anaesthesia and postoperative nausea and vomiting. Apart from significantly reducing the incidence of oculocardiac reflex (30% vs. 70%, p = 0.0019), peribulbar bupivacaine also attenuated the severity of the reflex. Postoperative pain relief was superior in the block group. More block group patients had the maximum recovery score in the immediate postoperative period (80% vs. 27%, p < 0. 0001) and they achieved complete recovery significantly faster than the morphine group (17.3 (14.7) min vs. 66.7 (29.7) min, p < 0.0001). The incidence (40% vs. 77%, p = 0.004) and severity of postoperative nausea and vomiting were significantly less in the block group. In summary, peribulbar bupivacaine, when administered together with general anaesthesia, attenuated oculocardiac reflex, provided comparable intra-operative and superior postoperative analgesia, resulted in significantly earlier and better recovery from anaesthesia, and significantly reduced the incidence and severity of postoperative nausea and vomiting.     

Usefulness of pre-emptive peribulbar block in pediatric vitreoretinal surgery: a prospective study

BACKGROUND AND OBJECTIVES: Vitreoretinal (VR) surgery with or without scleral buckling is associated with significant postoperative pain and emesis in adults, and recent studies have addressed the effect of retro or peribulbar block on these parameters. VR surgery in children has received little attention regarding the incidence of pain and emesis, and the role of regional anesthesia in modifying these parameters. In this study, we compared peribulbar block with conventional opioid analgesia in children undergoing VR surgery. METHODS: In a prospective, randomized, single-blind study, 85 children (ages 6 to 13 years) were allocated to receive peribulbar block (n = 42) or intravenous meperidine 1 mg/kg (n = 43) after induction of general anesthesia. Parameters compared were: intraoperative incidence of oculocardiac reflex and requirement for additional analgesic; postoperative pain intensity; incidence of postoperative emesis; time to first analgesic, total number of postoperative analgesic supplements; and parental assessment of the child's postoperative comfort at 24 hours. RESULTS: The incidence of intraoperative oculocardiac reflex was significantly less in the peribulbar group (P =.0001). Significantly more children receiving peribulbar block were pain free on awakening (P =.0004) and throughout the postoperative period. The number of children requiring opioid was significantly lower with peribulbar block (P =.008), and a significant number of children did not vomit throughout the postoperative period (P =.001). CONCLUSIONS: Peribulbar block appears to be a safe and clinically superior alternative to intravenous opioid for pediatric VR surgery.     

A prospective randomised double blind study to evaluate the effect of peribulbar block or topical application of local anaesthesia combined with general anaesthesia on intra-operative and postoperative complications during paediatric strabismus surgery

We studied 45 ASA I/II children aged between 2 and 13 years scheduled for elective strabismus surgery, randomly allocated to receive either a peribulbar block or topical lidocaine 2% combined with general anaesthesia, or general anaesthesia alone. The incidence and severity of the occulocardiac reflex, the requirement for atropine, the occurrence of arrhythmias and incidence of postoperative nausea and vomiting following surgery at 1, 2 and 4 h were studied. We found the incidence and severity of occulocardiac reflex intra-operatively was significantly reduced in children who received a peribulbar block. The incidence of postoperative nausea and vomiting was significantly reduced in patients receiving either peribulbar block or topical local anaesthesia combined with general anaesthesia, compared to general anaesthesia alone (p = 0.008).     

Preoperative peribulbar block in patients undergoing retinal detachment surgery under general anesthesia: a randomized double-blind study

Retinal detachment surgery is frequently associated with significant postoperative pain and emesis in adults. In this randomized, double-blind, controlled study we sought to demonstrate that 1% ropivacaine peribulbar (PB) block in conjunction with general anesthesia (GA) improves operative conditions and postoperative analgesia compared with GA combined with subcutaneous normal saline injection into the inferior eyelid. Thirty-one patients were included in each group. Anesthesia was performed with target-controlled infusion propofol and continuous remifentanil infusion adjusted to maintain bispectral index values between 40 and 50. Postoperative analgesia included fixed-dose IV infusion of propacetamol and IV injection of nefopam via a patient-controlled analgesia device. Tramadol was infused IV as rescue medication. Demographic data were comparable between the groups and bispectral index values were maintained at the objective target. In the PB group, fewer patients presented an oculocardiac reflex (6 versus 17; P < 0.01); bleeding interfering with the surgical field was reduced (1 versus 11 patients; P < 0.01); mean time to first nefopam request was longer (148 +/- 99 versus 46 +/- 58 min; P < 0.01); mean nefopam consumption was diminished during the first 6 h after tracheal extubation (18.9 +/- 13.9 versus 28.5 +/- 14.7 mg; P < 0.05); immediate postoperative pain scores were lower; and fewer patients required rescue medication (5 versus 23; P < 0.01). The two groups were similar with respect to the incidence of postoperative nausea and vomiting. Overall, PB block combined with GA improved operating conditions and postoperative analgesia in retinal detachment surgery.     

Pitfalls of anesthesiologic management in paediatric strabismus surgery

Strabismus surgery is one of the most common paediatric operation procedures. As associated with congenital syndrome, congenital heart disease and neuromuscular disorder, the anesthesiologic management has to be planned carefully. Considering high incidences of oculocardiac reflex (OCR) and postoperative nausea and vomiting (PONV) anesthesia can be performed to decrease both. Induction of anesthesia with ketamine or midzolam reduces risk of oculocardiac reflex, whereas propofol or remifentanil lead to higher incidences of OCR. A combination anti-emetic therapy from different drug classes is recommend to patients at high risk for nausea and vomiting like patients undergoing strabismus surgery. A combination therapy of ondansetron and dexamethasone lead to a risk reduction of PONV to at least 10 %. Further, the incidence of OCR and PONV is significantly reduced in children receiving peribulbar block on top of general anaesthesia.     

A randomised comparison of lidocaine 2% gel and proparacaine 0.5% eye drops in paediatric squint surgery

We conducted a randomised trial comparing lidocaine 2% gel with proparacaine 0.5% eye drops in children having elective squint surgery. One hundred and forty children aged between 3 and 14 years were recruited. The requirement for intra‐operative fentanyl and postoperative ibuprofen was significantly less in the lidocaine group compared with the proparacaine group (1 (1.7%) vs 12 (18.5%), p = 0.002 and 16 (27.6%) 38 (58.5%), p = 0.001, respectively). The incidence of postoperative nausea and vomiting was significantly less in the lidocaine group compared with the proparacaine group (6 (10.3%) vs 16 (24.6%), p = 0.04). There were no differences between the groups in terms of incidence and severity of the oculocardiac reflex. We conclude that, compared with proparacaine 0.5% eye drops, a single application of lidocaine 2% gel improves peri‐operative analgesia and reduces the incidence of postoperative nausea and vomiting in elective paediatric squint surgery.     

Propofol-nitrous oxide versus sevoflurane-nitrous oxide for strabismus surgery in children

Vomiting is a common problem following strabismus surgery. We compared the effects of propofol-N2O and sevoflurane-N2O on the incidence of oculocardiac reflex and postoperative nausea and vomiting. Forty unpremedicated children, aged 3-15 years were randomly assigned to two groups of 20 patients. In group 1, anaesthesia was induced and maintained with propofol infusion (173 +/- 41 micrograms.kg-1.min-1). In group 2, anaesthesia was induced with N2O (66%) in O2 and incremental sevoflurane via face mask and maintained with sevoflurane. Both groups received 66% N2O in O2 throughout surgery. The overall incidence of vomiting and antiemetic requirement in the first 24 h was significantly higher in sevoflurane-N2O group than propofol-N2O group (P < 0.05). The propofol-N2O group had significantly more episodes of oculocardiac reflex than sevoflurane-N2O group (P < 0.05). Propofol-N2O anaesthesia results in a significantly lower incidence of postoperative vomiting, yet a significantly higher incidence of oculocardiac reflex.     

Safety and efficacy of peribulbar block as adjunct to general anaesthesia for paediatric ophthalmic surgery

METHODS: Fifty children (age 5-14 years, ASA I-II) undergoing elective ophthalmic surgery were chosen for the study. Of these, 25 received intravenous pethidine (control group) and 25 received a peribulbar block (block group) for perioperative analgesia, and were monitored intraoperatively and postoperatively by an investigator blinded to the analgesic technique. RESULTS: Intraoperative values of haemodynamic variables were significantly higher in the control group (P < 0.01). Requirement for intraoperative rescue analgesic and postoperative analgesia was higher in the control group (P < 0.05 and P < 0.001, respectively). Children in the block group had lower postoperative pain scores at all times. Incidence of oculocardiac reflex was significantly higher (P < 0.001) in the control group. Seventy-six percent of children in the control group had postoperative nausea and vomiting compared to 20% children in the block group (P < 0.001). CONCLUSION: There were no complications related to the block. Peribulbar block appears to be a safe and useful analgesic technique for paediatric ophthalmic surgery.     

Anaesthesia for paediatric eye surgery

Local anaesthesia is often the technique of choice for ophthalmic procedures performed on adults; however, general anaesthesia is usually required for procedures on children. The majority of paediatric patients are fit and healthy but there is a minority in whom the presenting eye complaint is related to a congenital disorder, which may have significant bearing on the conduct of anaesthesia.Management of the airway and presentation of a quiescent eye for surgery are key considerations, while control of the oculocardiac reflex and intraocular pressure (IOP) are important both intraoperatively and postoperatively. IOP is affected by almost all aspects of general anaesthesia and should be considered when choosing an anaesthetic technique. Ocular surgery is emetogenic and without prophylaxis is associated with a high incidence of postoperative nausea and vomiting which should be addressed to prevent problematic increase in intraocular pressure. Most procedures are associated with mild to moderate postoperative pain and can usually be managed with simple analgesia. Pain, but also the use of opioid analgesia, is a risk factor for postoperative nausea and vomiting. Examination under anaesthesia, intraocular surgery, correction of squint and emergency ophthalmic surgery each presents its own challenge and all are discussed.     

Myopexy (Faden) results in more postoperative vomiting after strabismus surgery in children

BACKGROUND: Strabismus correction in children is associated with a high incidence of postoperative nausea and vomiting. The purpose of this prospective, double-blind study was to examine the influence of the surgical method for correction of squint on the incidence of postoperative vomiting. METHODS: One hundred and twenty consecutive children aged 2-12 years, scheduled for elective strabismus surgery, were enrolled in this prospective, double-blind study. A standardised total intravenous anaesthesia was given to all children. The development of perioperative oculocardiac reflex was noted and the number of episodes of vomiting during the first 48 h postoperatively was recorded. At the completion of the study, the children who were operated with myopexy according to Faden, were allocated to a Faden group, those without a myopexy to the non-Faden group. All the patients included in this study were operated on by the same surgeon with standardised techniques. RESULTS: The Faden group was younger, lighter and the operation time was longer (P<0.05). The incidence of vomiting was greater in the Faden group; 53% versus 12% (P<0.05). The incidence of oculocardiac reflex was similar in both groups; 40% in the Faden versus 28% in the non-Faden group, respectively. The total dose of propofol and alfentanil was similar between the groups. Requirement of analgesics for postoperative pain was similar in both groups. The only independent risk factor for postoperative vomiting was the Faden operation. CONCLUSION: The surgical method used for strabismus correction in children has a great influence on the incidence of postoperative vomiting. The Faden operation is associated with a very high incidence of postoperative vomiting; this particular group of patients has to be considered as a high risk group for postoperative vomiting and deserves an antiemetic prophylaxis.     

Nerve-stimulator guided paravertebral blockade vs. general anaesthesia for breast surgery: a prospective randomized trial

BACKGROUND AND OBJECTIVE: Different anaesthetic techniques are used during breast surgery but are frequently associated with unsatisfactory postoperative analgesia. Paravertebral nerve blockade has recently been proposed as a favourable alternative for this type of surgical procedure, providing excellent pain relief and a reduced incidence of postoperative nausea and vomiting. The aim of the present study was to compare the use of a nerve-stimulator guided paravertebral nerve blockade technique to regular general anaesthesia for breast surgery. METHODS: Sixty patients were prospectively randomized to receive either paravertebral nerve blockade or general anaesthesia for breast surgery. The primary end-point of the study was to assess postoperative analgesia (visual analogue scale and supplemental opioid requirements); the incidence of postoperative nausea and vomiting and length of hospital stay were considered as secondary outcome measures. RESULTS: Visual analogue scores both at rest and at movement, as well as the need for supplemental opioid administration during the first 3 days postoperatively, were significantly lower in patients handled with para-vertebral nerve blockade compared to patients receiving general anaesthesia (P < 0.05). The number of patients free from nausea and vomiting after operation was significantly higher in the paravertebral nerve blockade group (93%) compared to the general anaesthesia group (67%) (P < 0.05). The use of paravertebral nerve blockade was also associated with a significantly shorter hospital stay (median 1 day) compared to general anaesthesia (2 days) (P < 0.01). Both the performance of the block and the intraoperative conditions was well accepted by the vast majority of patients treated by paravertebral nerve blockade (97%). CONCLUSION: The use of paravertebral nerve blockade was associated with improved postoperative pain relief, a reduced incidence of nausea and vomiting after operation and a shorter duration of hospital stay compared to general anaesthesia in patients undergoing breast surgery.     

Anaesthesia for eye surgery in paediatrics

Children are rarely able to tolerate being awake for any type of surgery under local anaesthesia, therefore the majority of paediatric eye surgery is performed under general anaesthesia. Most patients presenting on a paediatric ophthalmology operating list will be otherwise healthy children who are suitable for day surgery. However, some children may have eye abnormalities as part of a congenital disorder. The perioperative plan should be formulated after assessment of the child's behaviour, co-existing medical issues and the surgical conditions required for the specific procedure. Factors influencing Intraocular pressure may require to be controlled, and anaesthetists should be vigilant for the oculocardiac reflex. Postoperative nausea and vomiting (PONV) is increased in ocular surgery, particularly with strabismus correction. Pain and opioid analgesics can both increase the risk of PONV. In most cases, simple analgesia and the intraoperative use of topical local anaesthesia will provide effective postoperative pain relief.     

A preoperative retrobulbar block in patients undergoing scleral buckling reduces pain, endogenous stress response, and improves vigilance

BACKGROUND AND OBJECTIVES: This study aims to test postoperative analgesia by using retrobulbar block in patients with retinal detachment surgery. METHODS: Twenty-nine patients scheduled for scleral buckling were included in this double-blind, randomized, prospective study. After induction of general anesthesia and opening of the conjunctiva, patients received either 4 mL bupivacaine 0.5% or 4 mL saline 0.9% injected into the retrobulbar space preoperatively. Heart rate and blood pressure were documented before the start of anesthesia, 10 and 50 minutes later, and 60 minutes after completion of surgery. At the same time points, 10 mL of blood were withdrawn for measurement of glucose and cortisol levels to evaluate the efficacy of retrobulbar block in eliminating humoral response. Postoperative scores for pain and vigilance were recorded 1, 6, and 24 hours after completion of surgery. The application of analgesic and antiemetic drugs was documented, as well as occurrence of nausea and vomiting. RESULTS: A preoperative retrobulbar block in patients undergoing scleral buckling reduces pain, endogenous stress response, and improves vigilance. CONCLUSIONS: Because the analgesic effect of the retrobulbar block was considerably longer than pharmacologically expected, the combined retrobulbar and general anesthesia "protects" against postoperative pain and is recommended for patients undergoing scleral buckling.     

Bilateral paravertebral somatic nerve block for ventral hernia repair

BACKGROUND AND OBJECTIVE: Unilateral paravertebral nerve blockade has been reported to produce excellent afferent nerve block, reduce the incidence of postoperative nausea and vomiting, and reduce hospital stay following inguinal hernia repair. The aim was to compare the use of bilateral paravertebral blocks to regular general anaesthesia for ventral hernia repair. METHODS: Sixty patients were prospectively allocated to receive either bilateral paravertebral nerve blockade (midazolam for block; supplemented with light intraoperative sedation if needed) or general anaesthesia for ventral hernia repair. The end-points of the study were length of hospital stay, postoperative analgesia (visual analogue scale, supplemental opioid requirement) and incidence of postoperative nausea and vomiting. RESULTS: The duration of hospital stay was observed to be shorter in patients handled with bilateral paravertebral nerve blockade (2.3 [SD 1.3] days) compared with patients receiving general anaesthesia (4.1 (3.0) days). Paravertebral analgesia resulted in both lower visual analogue scores and a significantly reduced need for supplemental opioid administration during the first 48 h postoperatively compared with general anaesthesia (P < 0.001). The rate of postoperative nausea and vomiting in the paravertebral nerve blockade group was only 3.3%, while 26.7% of patients in the general anaesthesia group suffered from postoperative nausea and vomiting (P < 0.05). Paravertebral nerve blockade was associated with good patient acceptance in 90% of patients. CONCLUSIONS: Bilateral paravertebral blockade combined with light intravenous sedation was superior to general anaesthesia for ventral hernia repair. Paravertebral blockade was associated with shorter hospital stay, improved analgesia and less postoperative nausea and vomiting. It is suggested that this technique deserves more widespread use in patients undergoing ventral hernia repair.     

Effect of timing of ondansetron administration on incidence of postoperative vomiting in paediatric strabismus surgery

This prospective, randomized, double-blinded study evaluated the effect of the timing of ondansetron administration on its antiemetic efficacy in children undergoing elective strabismus surgery. One hundred and twenty children aged one to 15 years, ASA physical status 1 or 2, were randomly allocated to receive intravenous ondansetron 100 micrograms/kg either at induction (Group 1) or at the end of the surgery (Group 2). All patients had general anaesthesia induced and maintained with nitrous oxide and halothane, muscle relaxation with vecuronium, endotracheal intubation, reversal with neostigmine and glycopyrrolate, and pethidine 0.5 mg/kg analgesia. Episodes of nausea and vomiting were evaluated at 0 to 2, 2 to 6 and 6 to 24 hour intervals by a blinded observer. Demographic data, duration of anaesthesia, type of surgery, incidence of previous postoperative nausea or vomiting and motion sickness and number of patients who developed oculocardiac reflex requiring atropine treatment were similar in both groups. The incidence of emesis in the first 24 hours following surgery was similar in both groups (35% Group 1, 33.3% Group 2, P = 1.00). Severity of emesis (median number of emetic episodes, rescue antiemetic requirement and mean time to the onset of first episode of emesis) and mean time to discharge from the post anaesthesia care unit were also similar in the two groups. We conclude that the timing of ondansetron administration either before or after the surgical manipulation of extraocular muscles had similar antiemetic efficacy following strabismus surgery in children.     

Peribulbar anesthesia with either 0.75% ropivacaine or a 2% lidocaine and 0.5% bupivacaine mixture for vitreoretinal surgery: a double-blinded study.

No study has evaluated the efficacy of ropivacaine in peribulbar block for ophthalmic surgery. The purpose of this prospective, randomized, double-blinded study was to compare ropivacaine and a lidocaine-bupivacaine mixture in peribulbar anesthesia. Sixty ASA physical status I or II patients scheduled for elective vitreoretinal surgery were randomized to receive a peribulbar block with 8 mL of either 0.75% ropivacaine (ropivacaine group, n = 30) or a 1:1 mixture of 2% plain lidocaine and 0.5% plain bupivacaine (lido-bupivacaine group, n = 30). Time required for onset of surgical anesthesia, quality of postoperative analgesia, incidence of side effects, and analgesic consumption were recorded. Surgical block was achieved after 8 +/- 5 min in the lido-bupivacaine group and after 10 +/- 5 min in the ropivacaine group (P = 0.23). A 3-mL supplemental injection 15 min after block placement was required in 6 patients in the lido-bupivacaine group (20%) and in 10 patients in the ropivacaine group (33%) due to inadequate motor block (P = 0.38). On Postoperative Day 1, 26 patients in the ropivacaine group (87%) reported no pain at the verbal rating score, compared with 18 patients in the lido-bupivacaine group (60%) (P = 0.005). We conclude that 0.75% ropivacaine may be a suitable choice when performing peribulbar anesthesia for vitreoretinal surgery. IMPLICATIONS: Quick onset of block with prolonged postoperative analgesia is an important goal in regional anesthesia for ophthalmic surgery. Evaluating clinical properties of 0.75% ropivacaine and a 1:1 mixture of 2% lidocaine and 0.5% bupivacaine for peribulbar anesthesia, we demonstrated that ropivacaine has an onset similar to that of the lidocaine-bupivacaine mixture and provides a better quality of postoperative analgesia.     

Combined thoracic paravertebral and pectoral nerve blocks for breast surgery under sedation: a prospective observational case series

Avoidance of general anaesthesia for breast surgery may be because of clinical reasons or patient choice. There is emerging evidence that the use of regional anaesthesia and the avoidance of volatile anaesthetics and opioid analgesia may have beneficial effects on oncological outcomes. We conducted a prospective observational case series of 16 breast cancer surgeries performed under thoracic paravertebral plus pectoral nerve block with propofol sedation to demonstrate feasibility of technique, patient acceptability and surgeon satisfaction. Fifteen out of 16 cases were successfully completed under sedation and regional anaesthesia, with one conversion to general anaesthesia. Eleven out of 16 cases required low‐dose intra‐operative opioid analgesia. Out of the 15 surgical procedures completed under regional anaesthesia with sedation, all patients experienced either no or minimal intra‐operative pain, and all would choose this anaesthetic technique again. Surgeon‐reported operating conditions were ‘indistinguishable from general anaesthesia’ in most cases, and surgeons were ‘extremely satisfied’ or ‘satisfied’ with the technique after every procedure. Combined thoracic paravertebral plus pectoral nerve block with intra‐operative sedation is a feasible technique for breast surgery.     

Impact of spinal anaesthesia vs. general anaesthesia on peri‐operative outcome in lumbar spine surgery: a systematic review and meta‐analysis of randomised,controlled trials

Lumbar spinal surgery is most commonly performed under general anaesthesia. However, spinal anaesthesia has also been used. We aimed to systematically review the comparative evidence. We only included randomised, controlled trials in this meta‐analysis and calculated the risk ratio or standardised mean difference for haemodynamics, blood loss, surgical time, analgesic requirement, nausea and/or vomiting, and length of hospital stay. Eight studies with a total of 625 patients were included. These were considered to be at high risk of bias. Compared with general anaesthesia, the risk ratio (95% CI ) with spinal anaesthesia for intra‐operative hypertension was 0.31 (0.15–0.64), I² = 0% (p = 0.002); for intra‐operative tachycardia 0.51 (0.30–0.84), I² = 0% (p = 0.009); for analgesic requirement in the postanaesthesia care unit 0.32 (0.24–0.43), I² = 0% (p < 0.0001); and for nausea/vomiting within 24 h postoperatively 0.29 (0.18–0.46), I² = 12% (p < 0.00001). The standardised mean difference (95% CI ) for hospital stay was ?1.15 (?1.98 to ?0.31), I² = 89% (p = 0.007). There was no evidence of a difference in intra‐operative hypotension and bradycardia, blood loss, surgical time, analgesic requirement within 24 h postoperatively, and nausea/vomiting in the postanaesthesia care unit. We conclude that spinal anaesthesia appears to offer advantages over general anaesthesia for lumbar spine surgery.     

Use of paravertebral block anesthesia in the surgical management of breast cancer: experience in 156 cases.

OBJECTIVE: To assess safety and efficacy of the regional anesthetic technique paravertebral block for operative treatment of breast cancer, and to compare postoperative pain, nausea, vomiting, and length of hospital stay in patients undergoing breast surgery using paravertebral block and general anesthesia. BACKGROUND: General anesthesia is currently the standard technique used for surgical treatment of breast cancer. Increasing hospital costs have focused attention on reducing the length of hospital stay for these patients. However, the side effects and complications of general anesthesia preclude ambulatory surgery for most patients undergoing breast surgery. In April 1994, the authors initiated the use of paravertebral block anesthesia for patients undergoing primary breast cancer surgery. A review of our early experience revealed that this regional anesthetic technique enables effective anesthesia for operative procedures of the breast and axilla, reduces postoperative nausea and vomiting, and provides prolonged postoperative sensory block that minimizes narcotic requirements. METHODS: A retrospective analysis of 145 consecutive patients undergoing 156 breast cancer operations using paravertebral block and 100 patients undergoing general anesthesia during a 2-year period was performed. Anesthetic effectiveness and complications, inpatient experience with postoperative pain, nausea, vomiting, and length of stay were measured. RESULTS: Surgery was successfully completed in 85% of the cases attempted by using paravertebral block alone, and in 91% of the cases, surgery was completed by using paravertebral block supplemented with local anesthetic. There was a 2.6% incidence of complications associated with block placement. Twenty percent of patients in the paravertebral group required medication for nausea and vomiting during their hospital stay compared with 39% in the general anesthesia group. Narcotic analgesia was required in 98% of general anesthesia patients, as opposed to 25% of patients undergoing paravertebral block. Ninety-six percent of patients having paravertebral block anesthesia were discharged within the day of surgery, compared with 76% of patients who had a general anesthetic. CONCLUSIONS: Paravertebral block can be used to perform major operations for breast cancer with minimal complications and a low rate of conversion to general anesthesia. Paravertebral block markedly improves the quality of recovery after breast cancer surgery and provides the patient with the option of ambulatory discharge.     

General anaesthesia for ophthalmic surgery

The majority of ophthalmic surgeries are performed as day cases under topical or regional anaesthesia with or without intravenous sedation. However, general anaesthesia is necessary in certain circumstances e.g. local anaesthetic allergy or patients who are unable to cooperate or to lie flat or still. Patients for ophthalmic surgery are frequently elderly with multiple comorbidities, such as diabetes and hypertension. Patients with rare genetic syndromes may present for eye surgery. Therefore adequate preoperative evaluation and preparation will minimize perioperative complications. The goals of general anaesthesia are smooth induction and emergence, with stable intra-ocular pressure (IOP) and akinesia of the globe. These can be achieved with a combination of intravenous and inhalational agents with or without muscle relaxants and opiates. Use of the laryngeal mask airway has the advantage of causing a smaller rise in IOP on insertion and less coughing on emergence. Total intravenous anaesthesia with propofol and remifentanil has the advantages of causing less postoperative nausea and vomiting (PONV), reduced stress response to airway intervention, rapid recovery and smooth emergence. Some eye procedures require special consideration, for example, strabismus and vitreoretinal surgery involves traction of the rectus muscles producing a higher incidence of oculocardiac reflex and PONV. Most ophthalmic surgery produces mild to moderate pain amenable to non-opioid analgesics. Intraoperative topical and regional anaesthesia reduce postoperative pain and opiate requirement. Open globe injury and a full stomach present unique challenges to prevent increase in IOP as well as protecting the airway.