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.     

Posterior peribulbar anaesthesia for eye surgery

The efficacy, reliability, and safety of a modification of posterior peribulbar blockade for various types of ophthalmic procedures were investigated. In the present prospective study we describe the technical conditions of a nerve block considered to be less dangerous for patients. The incidence of failure was low, there was no adverse reaction, and the patients themselves judged the method favourably.     

Office-based anaesthesia for vitreoretinal surgery

The objectives of this study were to consider the effectiveness of local anaesthesia (LA) for office-based vitreoretinal (VR) surgery, the requirement to supplement the anaesthetic blockade, the demographic pattern of the sample and the acceptance of LA by patients. This prospective observational audit involved 111 patients that had undergone 128 VR procedures. Assessment data included: patient’s information, details of type of anaesthetic, and pain during surgery. A clinical audit was also carried out with telephone survey to establish the postoperative use of analgesics, the frequency of nausea, emesis, and insomnia. Results suggest that VR surgery can be carried out effectively and safely with LA, in an office-based surgery, provided that experienced surgeons exist. We noted a high degree of patient acceptance, a reasonable level of postoperative pain and a low frequency of nausea and vomits.     

Posterior peribulbar anaesthesia for intra-ocular surgery

Posterior peribulbar anaesthesia is a safe alternative to the better-known retrobulbar route because the local anaesthetic agent is deposited outside the ocular muscle cone and away from the retrobulbar nerves and blood vessels. The potential dangers of a retrobulbar injection are therefore greatly reduced but the same degree of anaesthesia and akinesia is achieved. The much safer and easier posterior peribulbar technique for intra-ocular surgery is described with reference to more than 400 cases.     

Articaine for sub-Tenon's and peribulbar anaesthesia in cataract surgery

Editor—Two recent articles describing the use of articaine2% for sub-Tenon's and peribulbar anaesthesia demonstrated asuperior block compared with the traditional bupivacaine 0.5%/lidocaine2% mixture.^{1 2} However, neither article commented on the longerterm (2 week) follow-up of these patients, with particular referenceto full recovery from block. The experience of articaine indental surgery should make us cautious if we choose to use thislocal anaesthetic in ocular blocks. Neurotoxicity was reportedby Haas and Lennon³ in a 21 yr retrospective study of paraesthesiaeafter     

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.     

Peribulbar anesthesia for primary vitreoretinal surgery.

We prospectively studied the efficacy of peribulbar anesthesia in 76 consecutive patients who underwent vitreoretinal surgery. The mean duration of anesthesia was 124.74 +/- 50.17 minutes, and the mean duration of akinesia, 151.5 +/- 54.45 minutes. Adequate anesthesia and akinesia, independent of the duration of surgery, was obtained in 26 of 33 (78.8%) patients who underwent vitrectomy; 9 of 32 (28.1%) who underwent scleral buckling; and 2 of 11 (18.2%) who underwent vitrectomy combined with scleral buckling. In all, topical and systemic supplementation of drugs for inadequate anesthesia or akinesia allowed 32 of the 33 (97%) vitrectomies, 30 of the 32 (94%) scleral buckling procedures, and all 11 of the combined surgeries to be completed as planned. Three (4%) patients vomited, moved, or were restless, resulting in an operative complication or postponement of surgery. Fifty-eight (76%) said they would desire similar anesthesia if subsequent surgery was needed in the same or fellow eye. We conclude that peribulbar anesthesia should be considered primarily for patients requiring vitreous surgery alone, and as an alternative for patients requiring scleral buckling or combined surgery for whom general anesthesia is contraindicated.     

Articaine versus lidocaine plus bupivacaine for peribulbar anaesthesia in cataract surgery

Background. We compared the efficacy and safety of articaine2% with a mixture of lidocaine 2% and bupivacaine 0.5% withouthyaluronidase for peribulbar anaesthesia in cataract surgery. Method. In this double-blind randomized clinical study, 58 cataractpatients were allocated to receive either articaine 2% withepinephrine 1:200 000 or a mixture of equal parts of lidocaine2% with epinephrine 1.25:100 000 and bupivacaine 0.5%. Ocularand eyelid movement scores, the number of supplementary injections,total volume of solution used and pain and complications duringinjection and surgery were used as clinical end-points. Results. Articaine produced greater akinesia after 5 min (P=0.03).Eighteen patients (60%) in the articaine group and 26 (93%)in the lidocaine/bupivacaine group required a second injection(P=0.003). A third injection was needed by two patients (7%)in the articaine group and 12 (43%) in the lidocaine/bupivacainegroup (P=0.001). The total mean volume of local anaestheticrequired to achieve akinesia was mean 9.4 (SD 1.7) ml in thearticaine group and 11.28 (1.86) ml in the lidocaine/bupivacainegroup (P<0.001). Median pain score was lower in the articainegroup than in lidocaine/bupivacaine group during injection (P=0.004)and surgery (P=0.014). There was no difference between the groupsfor the incidence of complications. Conclusion. Articaine 2% without hyaluronidase is more advantageousthan a mixture of lidocaine 2% and bupivacaine 0.5% withouthyaluronidase for peribulbar anaesthesia in cataract surgery. Br J Anaesth 2004; 92: 231–4     

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.     

Intravenous sedation prior to peribulbar anaesthesia for cataract surgery in elderly patients

Purpose

To investigate if pre-block iv sedation using midazolam, alfentanil, or a midazolam-alfentanil combination minimizes pain, reduces pain recall, and attenuates haemodynamic responses to peribulbar block; and to determine other factors influencing oxygen saturation (SpO₂) following iv sedation.

Methods

In a randomized, double-blind, placebo-controlled study, 120 patients, mean age 73 yr, having cataract surgery with peribulbar anaesthesia, were randomized to receive either normal saline, 1 mg midazolam, 500 μg alfentanil, or 0.5 mg midazolam plus 250 μg alfentanil. Blood pressure (BP), heart rate (HR) and pulse oximetry readings were recorded before injection of the study drugs, immediately after completion of the peribulbar block, and 10 min after the block. Pain from the anaesthetic block was assessed immediately after the block and after surgery using a visual analog scale, and recall of pain was assessed by telephone on the day after surgery.

Results

Pain scores were low in all four groups. Midazolamalfentanil reduced pain perception, and all iv sedation used reduced pain recall. Midazolam reduced systolic BP; alfentanil ± midazolam reduced HR. All iv sedation reduced SpO₂ more than did saline, but not usually to a clinically important level. Nine patients had a SpO₂ S 90%; all had received alfentanil with or without midazolam. It was not possible to predicoxygen saturation levels by any factors other than iv sedation and baseline SpO₂ levels.

Conclusion

Intravenous sedation with midazolam or alfentanil or in combination reduced pain perception, pain recall, and haemodynamic responses from peribulbar anaesthesia. Fifteen percent of patients given alfentanil developed clinically important oxygen desaturation. The use of fine gauge needles combined with slow injection of anaesthetic solution causes minimal discomfort, and routine iv sedation may be unnecessary.     

Effect of the use of dexmedetomidine as an adjuvant in peribulbar anesthesia in patients presented for vitreoretinal surgeries

Background

Dexmedetomidine, if used in combination with a local anesthetic mixture in peribulbar anesthesia, may alter the block characteristic. This research aimed to study the influence of adding dexmedetomidine to local anesthetics in the peribulbar block.

Comparative outcome analysis of spinal anesthesia versus general anesthesia in lumbar fusion surgery

IntroductionSpinal anesthesia (SA) has been shown in several studies to be a viable alternative to general anesthesia (GA) in laminectomies, discectomies, and microdiscectomies. However, the use of SA in spinal fusion surgery has been very scarcely documented in the current literature. Here we present a comparison of SA to GA in lumbar fusion surgery in terms of perioperative outcomes and cost.MethodsThe authors retrospectively reviewed the charts of all patients who underwent 1- or 2-level minimally invasive transforaminal lumbar interbody fusion (TLIF) surgery by a single surgeon, at a single institution, from 2015 to 2018. Data collected included demographics, operative and recovery times, nausea/vomiting, postoperative pain, and opioid requirement. Costs were included in the analysis if they were: 1) non-fixed; 2) incurred in the operating room (OR); and 3) directly related to patient care. All cost data represents net costs and was obtained from the hospital revenue cycle team. Patients were grouped for statistical analysis based on anesthetic modality.ResultsA total of 29 patients received SA and 46 received GA. Both groups were similar in terms of age, gender, BMI, number of levels operated upon, preoperative diagnosis, and medical comorbidities. The SA group spent less time in the OR (163.86 ± 9.02 vs. 195.63 ± 11.27 min, p < 0.05), PACU (82.00 ± 7.17 vs. 102.98 ± 8.46 min, p < 0.05), and under anesthesia (175.03 ± 9.31 vs. 204.98 ± 10.15 min, p < 0.05) than the GA group. Post-surgery OR time was significantly less with SA than with GA (6.00 ± 1.09 vs. 17.26 ± 3.05 min, p < 0.05); however, pre-surgery OR time was similar between groups (50.17 ± 3.08 vs. 56.17 ± 5.34 min, p = 0.061). The SA group also experienced less maximum postoperative pain (3.31 ± 1.41 out of 10 vs. 5.96 ± 0.84/10, p < 0.05) and required less opioid analgesics (2.38 ± 1.37 vs. 5.39 ± 0.84 doses, p < 0.05). Both groups experienced similar nausea or vomiting rates and adverse events postoperatively. Net operative cost was found to be $812.31 (5.6%) less with SA than with GA, although this difference was not significant (p = 0.225).Discussion/conclusionTo our knowledge, SA is almost never used in lumbar fusion, and a cost-effectiveness comparison with GA has not been recorded. In this retrospective study, we demonstrate that the use of SA in lumbar fusion surgery leads to significantly shorter operative and recovery times, less postoperative pain and opioid usage, and slight cost savings over GA. Thus, we conclude that this anesthetic modality represents a safe and cost-effective alternative to GA in lumbar fusion.     

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.     

Dexmedetomidine infusion as a supplement to isoflurane anaesthesia for vitreoretinal surgery

Background: We explored the sympatholytic property of dexmedetomidine, especiallyits role in intraocular pressure (IOP) reduction, haemodynamicstability, and attenuation of extubation response. Method: In this double-blind, randomized, controlled trial approvedby the Hospital Ethics Committee, 60 patients undergoing electivevitreoretinal surgery were allocated to two groups, receivingeither placebo or dexmedetomidine. A loading dose of dexmedetomidine2.5 µg kg^–1 h^–1 (or placebo in same volume)was infused for 10 min immediately before induction of anaesthesiawith propofol, followed by a maintenance dexmedetomidine orplacebo infusion at 0.4 µg kg^–1 h^–1 till 30min before the end of the operation. Anaesthesia was maintainedwith isoflurane, oxygen, and air mixture. IOP was measured beforethe loading dose and 1 min after tracheal intubation. The meanarterial pressure (MAP) and heart rate (HR) during loading,induction, maintenance, extubation, and recovery period weremeasured. The degree of strain on extubation was graded from0 to 5. Results: The use of vasopressor/labetalol/atropine and the reductionin IOP were comparable between the two groups. There was a significantvariation in MAP and HR over time within group, but not betweengroups. The median degree of strain was significantly lower(P = 0.049), and the time to reach Aldrete score of 10 shorter(P = 0.031) in the dexmedetomidine group. Conclusion: Dexmedetomidine can be used without undue haemodynamic fluctuationand can decrease the excitatory response during extubation.The reduction in IOP with dexmedetomidine was comparable withplacebo.     

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).     

Brainstem anesthesia presenting as contralateral third nerve palsy following peribulbar anesthesia for cataract surgery

Brainstem anesthesia is a serious complication that has been reported to occur more commonly with retrobulbar anesthesia compared to peribulbar anesthesia. We herein report a case of contralateral third nerve palsy following administration of peribulbar anesthesia for cataract surgery. Two hours after the surgery, the patient recovered completely without any residual neurological deficit. The importance of immediate recognition of clinical signs and symptoms of central spread of the local anesthetic and the mechanical factors of the block that could have contributed to this complication are discussed in this report.     

A comparison of sub-Tenon's with peribulbar anaesthesia in patients undergoing sequential bilateral cataract surgery

The aim of this study was to compare efficacy and particularly patient preference of sub-Tenon's anaesthesia with peribulbar anaesthesia in patients undergoing sequential, bilateral, cataract surgery. Fifty patients were randomised to either sub-Tenon's or peribulbar anaesthesia for their first operation and the alternative technique for their subsequent operation. Intra-ocular pressure was measured, globe and lid akinesia were scored, patients completed a visual rating score of injection and operative pain and their preference for anaesthesia was assessed. Intra-ocular pressure rose significantly following peribulbar injection (p = 0.02) but was comparable at 5 min. There was no significant difference in lid or globe movement. Injection and operative pain scores were low and comparable. Both methods provided similar anaesthesia and akinesia. The majority (86%) chose the method they received first irrespective of whether it was sub-Tenon's or peribulbar, but 10% of patients preferred sub-Tenon's, disliking the facial numbness from peribulbar anaesthesia.