Comparison of lignocaine 2% with adrenaline, bupivacaine 0.5% with or without hyaluronidase and a mixture of bupivacaine, lignocaine and hyaluronidase for peribulbar block analgesia

PURPOSE: Each of the freely available local analgesic agents may be used, alone or in combination, with or without hyaluronidase, epinephrine and sodium bicarbonate for peribulbar block analgesia (PBA). A prospective audit of four solutions was undertaken to rationalize choice of local analgesic agent for PBA. METHODS: A randomized, prospective study on 200 middle-aged to elderly patients undergoing cataract extraction was undertaken to compare the efficacy of: (1) bupivacaine 0.5% (bup 0.5% plain); (2) bupivacaine 0.5% plus hyaluronidase 100 i.u. ml-1 (bup 0.5% hyalase); (3) lidocaine 2% plus epinephrine 1:200 000 (lido 2% epi); or (4) a mixture of lidocaine 2% and bupivacaine 0.5% (2:3 volume per volume mix) containing hyaluronidase 25 i.u. ml-1 (lido/bup/hyalase). A standardized deep peribulbar block technique, akinesia scoring system (each 5 minx4), and supplemental protocol was followed. Onset of block and supplementation rates to achieve akinesia were recorded by a blinded observer; the requirement for augmentation with topical oxybuprocaine or subconjunctival lidocaine during surgery and the time from first PBA injection to the completion of surgery (the duration of surgical access) were also recorded. RESULTS: Groups (N=50) were comparable. Akinesia scores were similar after each agent at 5 min, better with lido 2% epi compared with bup 0.5% plain at 10 min (P<0.05), and better with bup 0.5% hyalase, lido 2% epi, and lido/bup/hyalase, than with bup 0.5% plain at 15 min (P<0.01, <0.01, <0.05, respectively) and at 20 min (P<0.05, <0.05, <0.025, respectively). The supplementation rate at 5 min was least with lido 2% epi, greater with bup 0.5% plain (P<0.01) and bup 0.5% hyalase (P<0.0005) and greatest with lido/bup/hyalase (P<0.0005), but similar in each group at 10, 15 and 20 min. Overall, those given lido 2% epi required the least number of supplemental injections to achieve globe akinesia. Mean supplemental injectate volumes, augmentation rates during surgery and the durations of surgical access provided by each agent were similar. CONCLUSION: All four agents provided adequate analgesia during cataract extraction lasting approximately 95-100 min after PBA injection. Lido 2% epi demonstrated most rapid onset and required least number of injections to establish block. A hyaluronidase effect was evident only after 15 min in the bup 0.5% hyalase and lido/bup/hyalase groups. Bup 0.5% plain was overall the least satisfactory, and the greatest supplementation rate occurred with lido/bup/hyalase, suggesting that either lido 2% epi or bup 0.5% hyalase are the most suitable of the agents tested for this type of surgery.