Propofol-nitrous oxide versus thiopental sodium-isoflurane-nitrous oxide for strabismus surgery in children

The Oculocardiac Reflex: A Review

BACKGROUND

A typical oculocardiac reflex (OCR) is a moderate trigemino-vagal bradycardia elicited by tension on an extraocular muscle (EOM) during strabismus surgery; however, many other orbital stimuli can elicit cardiac slowing including retinopathy of prematurity examination.

METHODS

World literature related to trigeminovagal and oculocardiac reflex covering over 15,000 patients including 51 randomized clinical trials and case reports are analyzed and reviewed. Under an ongoing observational trial in Alaska, anesthetic, patient and surgical influences on routine strabismus surgery using prospective, uniform EOM tension are compared seeking sufficient sample size to characterize this individually widely variable cardiac response.

RESULTS

With adequate sample size, and emphasizing clinical studies controlling type of EOM, muscle tension amount and duration, anticholinergic and opioid medications, the following augment OCR; rapid-acting opioids and dexmedetomidine while OCR is reduced in older patients, the right eye, less EOM tension, deeper inhaled agents, hypocarbia, anticholinergic medications and orbital block. In re-operations, the former are relatively poor predictors of subsequent OCR.

CONCLUSION

Profound bradycardia can occur in almost 10% of strabismus surgery cases without anticholinergic preventive measures, but reliable prediction of OCR remains elusive. With foreknowledge and careful anesthetic monitoring of the patient before EOM manipulation, residual adverse sequelae from OCR are fortunately very rare. Despite well over a century of experience, the teleology for this occasionally dramatic cardiac response to eye surgery is still not known.

Anesthetic Impacts on the Oculocardiac Reflex: Evidence from a Large, Observational Study

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 CO₂.

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.

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Systematic review of day-case laparoscopic fundoplication

BACKGROUND

The aim of the current study is to review published literature on day-case laparoscopic fundoplication in adults.

DATA SOURCES

Medline, Embase, and Cochrane library was searched by using the medical subjects headings "ambulatory surgical procedures" and "fundoplication" with further free text search and cross references. All articles on planned day-case laparoscopic fundoplication that described patient selection criteria, same-day discharge, complications, and readmissions were reviewed.

CONCLUSIONS

Thirteen cohort studies were included in this review. Ten were on planned same-day discharge with a 93% (739 out of 792) success, 4% (34) complication, and 5% (39) readmission rate. Three studies were on planned 23 hour discharge with a 98% (571 out of 583) success, 4% (25) complications, and 1% (5) re-admission rate. Nausea, pain, fatigue, and pneumothorax were the commonest causes for overnight admission. Dysphagia and pain were the main reasons for readmission. Most patients were satisfied with day-case laparoscopic fundoplication.

Effect of different anesthetic agents on oculocardiac reflex in pediatric strabismus surgery

PURPOSE

The oculocardiac reflex (OCR) occurs frequently during pediatric strabismus surgery. The aim of this study was to assess the effects of various anesthetic regimens on the incidence of OCR during the surgery.

METHODS

Two hundred and eighty children, 1 to 9 years old, undergoing elective strabismus surgery, were randomly assigned to eight groups; ketamine-sevoflurane (KS), ketamine-desflurane (KD), ketamine-propofol (KP), ketamine-remifentanil (KR), midazolam-sevoflurane (MS), midazolam-desflurane (MD), midazolam-propofol (MP), and midazolam-remifentanil (MR). No premedication was given. Anesthesia was induced using ketamine 1 mg kg(-1) or midazolam 0.15 mg kg(-1) with 66% N(2)O in O(2). Laryngeal mask airways (LMAs) were placed with rocuronium 0.5 mg kg(-1). Anesthesia was maintained with sevoflurane 2-3 vol. %, desflurane 5-6 vol. %, propofol 7-8 mg kg(-1) h(-1), or remifentanil 0.75 microg kg(-1) over 1 min, followed by a continuous infusion of remifentanil 0.5 microg kg(-1) min(-1) with 66% N(2)O in O(2). Heart rate (HR) was recorded during extraocular muscle (EOM) manipulation. OCR was defined as a reduction in HR of more than 20% induced by the traction of an EOM.

RESULTS

In patients given ketamine, OCR occurred more frequently in the KP (65.7%) and KR (62.9%) groups than in the KD (29.4%) and KS (37.1%) groups (P < 0.05). In patients given midazolam, OCR occurred more frequently in the MP (54.3%) and MR (60.6%) groups than in the MD (36.4%) and MS (31.4%) groups (P < 0.05).

CONCLUSION

Propofol or remifentanil anesthesia was associated with a higher incidence of OCR during pediatric strabismus surgery than sevoflurane and desflurane anesthesia, when either ketamine or midazolam was used as an induction agent.

Prospective study of routine day-case laparoscopic modified Lind partial fundoplication

BACKGROUND

The aim of the present study was to prospectively assess the feasibility, safety, and acceptability of performing day-case laparoscopic modified Lind fundoplication for gastroesophageal reflux disease on a routine basis and to determine possible implications for health care costs to the hospital.

METHODS

All patients undergoing laparoscopic fundoplication between November 2005 and November 2007 under the care of one surgeon were included in the study. Inclusion criteria were American Society of Anesthesiologists (ASA) grade I and II with adequate home support. The surgical procedure was laparoscopic modified Lind fundoplication in all the cases. Patients were reviewed in the clinic at 6 weeks and were subsequently assessed through a structured postal questionnaire at a median of 1 year.

RESULTS

Over the 25-month period, a total of 130 laparoscopic modified Lind fundoplications were performed, of which 103 (79.2%) met the inclusion criteria for day-case surgery. The patients were 16 to 75 years of age. Ninety (87.4%) were discharged on the same day as planned, and 11 patients were admitted overnight because of nausea. At clinic follow-up at a median of 6 weeks all patients expressed satisfaction and were reflux free. There was a significant reduction of mean modified Visick score and visual analog scale for reflux at a median of 1 year after surgery.

CONCLUSIONS

Routine day-case laparoscopic modified Lind fundoplication for gastroesophageal reflux disease is safe and well tolerated, with high levels of patient satisfaction and reduced costs to the hospital. Patients with ASA grade >2 and redo antireflux surgery should not be considered for day-case surgery. Hospital readmission was required in less than 3% of patients after discharge home, but those readmissions were not related to early discharge on the same day of surgery.

Single bolus of intravenous ketamine for anesthetic induction decreases oculocardiac reflex in children undergoing strabismus surgery

BACKGROUND

Oculocardiac reflex (OCR) is a major complication of pediatric strabismus surgery. The aim of the present study was to determine whether a single bolus of intravenous (i.v.) ketamine for anesthetic induction can decrease OCR in children undergoing strabismus surgery.

METHODS

One hundred and twenty healthy children undergoing strabismus surgery were allocated to three groups using double-blind randomization. Anesthesia was induced with propofol 3 mg/kg in Group P, ketamine 1 mg/kg in Group K1, or ketamine 2 mg/kg in Group K2. Anesthesia was maintained with 3% sevoflurane in 50% N(2)O/O(2) in all patients. The baseline heart rate was obtained 30 s prior to the first traction of the extraocular muscle (EOM). OCR was defined as a development of arrhythmia or a decrease of more than 20% of the baseline heart rate during EOM traction.

RESULTS

The incidence of OCR was significantly lower in the ketamine groups (4/40 and 1/40 in Group K1 and K2, respectively) compared with the propofol group (14/40).

CONCLUSION

A single bolus of i.v. ketamine 1 or 2 mg/kg for anesthetic induction results in a lower incidence of OCR than propofol when combined with sevoflurane for maintenance in children undergoing strabismus surgery.

Audit of outpatient laparoscopic cholecystectomy. Universities of Melbourne HPB Group

BACKGROUND

Because the postoperative stay after laparoscopic cholecystectomy (LC) has shortened, it seemed that outpatient LC would be feasible. The aim of this study was to prospectively audit initial experience with outpatient LC at the Austin and Repatriation Medical Centre. We aimed to determine appropriate patient selection criteria, to devise anaesthetic and discharge protocols and to assess patient satisfaction at follow up.

METHODS

All patients presenting for LC were assessed for suitability, and those elective cases unlikely to have a duct stone and fulfilling the social criteria were studied. After standard anaesthetic and LC technique, patients recovered in the day surgery unit for up to 8 h and were discharged if stable. The hospital in the home nursing service monitored patients for 48 h and arranged readmission if needed. Patient satisfaction was assessed by independent telephone questionnaire 6 weeks postoperatively.

RESULTS

Forty-five patients (median age 43 years) underwent outpatient LC with a discharge rate of 82.3%, resulting in a cost saving of $984 per patient treated. One patient was readmitted, giving an overall success rate of 80%. After stricter implementation of the protocol in the second half of the study, the discharge rate rose to 92%. Patient acceptance of the technique was high at 84.5%.

CONCLUSIONS

The results of the first 45 patients show that it is possible to safely perform outpatient LC with a low admission rate in fit, elective patients who live close to medical care. Provided a strict anaesthetic protocol is followed, the technique has good patient acceptance and provides some economic benefit to the hospital.

Oculocardiac reflex in sedated patients having laser in situ keratomileusis

PURPOSE

To eliminate stress as a variable in assessing the frequency of the oculocardiac reflex during laser in situ keratomileusis (LASIK).

SETTING

Merida Ophthalmological Hospital and Oftalmedica, Mexico City, Mexico.

METHODS

A pulse oximeter registered the heart rate of 30 sedated patients having LASIK. Sedation was accomplished with a combination of midazolam and fentanyl. The heart rate was noted before and during suction. The results in 1 eye of each patient were recorded. Oculocardiac reflex was defined as a decrease of 10% or more of the basal heart rate.

RESULTS

Fourteen patients (46.7%) had a 10% or more decrease in heart rate when suction was applied. Ten of the 14 had a decrease in heart rate between 10% and 19%, 3 between 20% and 29%, and 1 of more than 30%. Two patients (6.6%) had an increase in the basal heart rate of more than 10%.

CONCLUSIONS

The findings suggest that the oculocardiac reflex occurs more frequently in sedated patients than in nonsedated patients.

Oral granisetron for strabismus surgery in children

PURPOSE

To determine the efficacy of oral granisetron in preventing postoperative vomiting (POV) following strabismus repair in children.

METHODS

In a randomized, double-blind, placebo-controlled trial, 73 pediatric patients received either placebo, 20 micrograms.kg-1 or 40 micrograms.kg-1 granisetron po 20 min before induction of anesthesia. No premedication was given, induction was with halothane and all children breathed spontaneously via a laryngeal mask airway. Maintenance was with isoflurane without the use of opioids. Ketorolac and acetaminophen were used for analgesia. The number of episodes and the severity of vomiting and retching were recorded for the first 24 hr postoperatively, as was the use of rescue antiemetics.

RESULTS

Granisetron 20 micrograms.kg-1 and 40 micrograms.kg-1 were more effective than placebo in reducing the incidence of POV during the first 24 hr (29% in both the granisetron groups vs 84% in the placebo group, P < 0.05). In addition, the number of children experiencing severe vomiting (> or = 3 episodes) was reduced in the granisetron 20 micrograms.kg-1 and 40 micrograms.kg-1 groups compared with placebo (4%, 8% and 48% respectively, P < 0.05). Patients in the granisetron group were discharged home earlier (105 min vs 124 min, P = 0.04). There was no difference in the incidence of POV between the two granisetron groups.

CONCLUSION

Preoperative oral granisetron in a dose of 20 micrograms.kg-1 provided effective prophylaxis against POV in children undergoing stabismus repair.

Perianesthesia care of adult and pediatric strabismus surgery patients

Strabismus procedures on children and adults are frequently performed in an outpatient setting. Perianesthesia care of patients having strabismus procedures may be optimized by recognizing the characteristics of strabismus patients, the frequently associated diagnoses that may affect perioperative care, and the specific surgical techniques used to treat strabismus. Complications including postoperative nausea, pain, prolonged PACU stay, and unplanned postoperative admissions can be minimized and treatment facilitated by preparing patients with preoperative instructions, careful choice of anesthetic agents and postoperative medications, and appropriate perioperative care. This report will provide a brief review of surgical strabismus, including current techniques, and present guidelines for perioperative care of pediatric and adult strabismus patients.

Oculocardiac reflex and postoperative vomiting in paediatric strabismus surgery. A randomised controlled trial comparing four anaesthetic techniques

BACKGROUND

Oculocardiac reflex (OCR) and postoperative vomiting are major complications of paediatric strabismus surgery.

METHODS

Children (3-16 yr) undergoing elective strabismus surgery as inpatients were randomly allocated to four anaesthetic techniques: (A) thiopentone induction and isoflurane maintenance; (B) as (A) plus ondansetron 5 mg x m(-2) i.v.; (C) propofol induction and maintenance; (D) as (C) plus lignocaine 2 mg x kg(-1) i.v. All children received prophylactic atropine 0.02 mg x kg(-1) and alfentanil. Nitrous oxide was omitted.

RESULTS

Data on 157 children were analysed. The cumulative incidence of vomiting within 6 and 24 h after surgery with thiopentone-isoflurane was 26% and 46%, respectively. Adding ondansetron decreased the incidence to 8% and 33%, respectively. This improvement was significant within 6 h only; the number-needed-to-treat was 5.5 (95% CI 2.9-46). Propofol was not different from thiopentone-isoflurane. The addition of lignocaine to propofol was of no benefit. The risk of an OCR was significantly increased with propofol (incidence 40%) compared with isoflurane (14%); the number-needed-to-harm was 3.9 (95% CI 2.6-8).

CONCLUSIONS

Thiopental-isoflurane-air/O2-alfentanil resulted in a moderate risk of vomiting. Adding ondansetron significantly decreased this risk, but 6 children have to be treated for one to benefit in the early postoperative period. Propofol and propofol-lignocaine showed no benefit on vomiting but significantly increased the risk of an OCR despite high-dose prophylactic atropine.

Does propofol reduce vomiting after strabismus surgery in children?

BACKGROUND

Previous studies have indicated that propofol anaesthesia may reduce the incidence of postoperative nausea and vomiting after strabismus surgery in children. This study was designed to investigate the incidence of vomiting after strabismus surgery at two different levels of propofol anaesthesia compared to thiopental/isoflurane anaesthesia.

METHODS

Ninety ASA class I or II children, aged 5-14 yrs were randomly assigned to one of three groups: Group T/I (n = 30) induction with 5 mg kg-1 of thiopental and maintenance with isoflurane, group P5 (n = 31) induction with propofol 2 mg kg-1, maintenance with propofol infusion 5 mg kg-1 h-1 or group P10 (n = 29) induction with propofol 2 mg kg-1, maintenance with propofol 10 mg kg-1 h-1. All received glycopyrrolate, vecuronium, fentanyl and controlled ventilation with O2/N2O 30/70. Ketorolac i.v. was given to prevent postoperative pain. If additional analgesia was needed, ibuprofen/acetaminophen or buprenorphine was given according to clinical need.

RESULTS

There were no differences between study groups with respect to age, weight, history of previous anaesthesia or emesis after previous anaesthesia, duration of anaesthesia, surgery or sleep after anaesthesia, or number of muscles operated. The incidence of vomiting was 37%, 29% and 28% in groups T/I, P5 and P10, respectively. There were no statistically significant differences between the three groups in the incidence of vomiting. The median age of patients who vomited was 7.5 (range 5.0-13.7) yrs while the median age of the patients who did not vomit was 9.1 (range 5.0-14.0) yrs (P < 0.01).

CONCLUSION

In the present study, propofol anaesthesia compared to thiopental/isoflurane anaesthesia did not reduce the incidence of vomiting following strabismus surgery in children.

Vomiting after strabismus surgery in children: ondansetron vs propofol

PURPOSE

To compare the antiemetic efficacy and costs associated with two anaesthetic regimens in children undergoing strabismus surgery. One regimen contained halothane, nitrous oxide and ondansetron, while the other contained propofol and nitrous oxide.

METHODS

Three hundred children aged 2-14 yr undergoing strabismus surgery were enrolled into this single-blind, randomized, stratified, blocked study with a balanced design. Anaesthesia was induced by inhalation with halothane/N2O/O2 (Group O) or with 2.5-3.5 mg.kg-1 propofol + 0.5 mg.kg-1 lidocaine i.v. (Group P). Group O patients were administered 0.15 mg.kg-1 ondansetron (maximum dose 8 mg) i.v. and all patients received atropine 20 micrograms.kg-1 i.v. immediately after induction of anaesthesia. Anaesthesia was maintained with N2O and halothane (Group O) or N2O and propofol (Group P). Patients were followed for 24 hr after their operation primarily to assess the incidence of postoperative vomiting. For each case, the costs of the anaesthetic drugs administered and their associated intravenous administration tubing were determined. Drug costs were those prevailing at the study site at the time of the investigation. Fixed costs, such as the cost of the anaesthetic equipment were not assessed.

RESULTS

Groups were similar with respect to demographic data. The incidence of vomiting in both groups was 11% while in-hospital and 23% after discharge. Each episode of in-hospital vomiting prolonged discharge by 17 +/- 4 min, P < 0.001. Mean cost per case for anaesthetic drugs was less in Group O, 18 +/- 8 vs 21 +/- 10, CDN$, mean +/- SD, P < 0.01.

CONCLUSION

The two methods of antiemetic prophylaxis were equally effective. Propofol-based anaesthesia was more expensive.

Postoperative nausea and vomiting: the outpatient enigma

Postoperative nausea and vomiting is an all too common side effect of surgery and anesthesia. The usual occurrence of vomiting within the first 24 hours following surgery involves one quarter to one third of all patients. Although nausea and vomiting is typically self-limiting, lasting less than 24 hours, the consequences must be considered. Patient dissatisfaction, adverse physiological sequelae, delays in discharge from the ambulatory facility, unanticipated hospital admission, and added cost are problems associated with postoperative vomiting. This article will review the multiple factors contributing to postoperative nausea and vomiting and discuss contemporary strategies for the management of these factors.

Total intravenous anesthesia for children undergoing brief diagnostic or therapeutic procedures

STUDY OBJECTIVE

To compare the quality of anesthesia with propofol, ketamine, or etomidate in children undergoing brief diagnostic or therapeutic procedures.

DESIGN

Retrospective study.

SETTING

University hospital.

PATIENTS

971 pediatric oncology patients undergoing brief diagnostic or therapeutic procedures outside the operating room during a one-year period.

INTERVENTIONS

Total intravenous anesthesia was administered primarily with ketamine, etomidate, or propofol for oncology-related procedures such as bone marrow aspiration, lumbar puncture, radiologic imaging, and radiation therapy. Quality assurance data were collected for all patients, including anesthetic technique, dosage, and the occurrence of specific adverse events during anesthesia and recovery periods.

MEASUREMENTS AND MAIN RESULTS

There were 279 anesthesia-related occurrences, comprised almost entirely of five specific events: vomiting, hypoxemia (SpO2 less than 94%), tachycardia, agitation, and myoclonus. Ketamine was associated with vomiting (14.6%), agitation (15.0%), and tachycardia (19.5%). Etomidate was also associated with vomiting (9.9%) and agitation (1.2%). Hypoxemia was rare except in the propofol group (15.7%) and was easily managed with supplemental oxygen, but occasionally required manually assisted ventilation via face mask. In patients receiving propofol vomiting (0.5%) and agitation (1.2%) were rare.

CONCLUSIONS

Anesthesia with propofol, ketamine, or etomidate is safe and efficacious for children undergoing brief procedures. Propofol is associated with a decreased incidence of postanesthetic agitation and vomiting. Its association with respiratory depression is confirmed.

Prevention of emesis after strabismus repair in children: a prospective, double-blinded, randomized comparison of droperidol versus ondansetron

STUDY OBJECTIVE

To compare the effectiveness of ondansetron with droperidol in preventing postoperative emesis in children after strabismus repair.

DESIGN

Randomized, double-blind study.

PATIENTS AND SETTING

57 ASA physical status I and II children aged 3 to 14 years, undergoing outpatient strabismus repair in two separate study centers.

INTERVENTIONS

Patients were randomized to receive either 0.15 mg/kg intravenous (i.v.) ondansetron or 0.075 mg/kg i.v. droperidol shortly after induction of anesthesia.

MEASUREMENTS AND MAIN RESULTS

Number of episodes of emesis and times to discharge from the recovery room and ambulatory center were assessed. Twenty-nine (94%) of 31 children who received ondansetron and 21 (81%) of 26 children who received droperidol were emesis-free (p = NS). There were no significant differences in the number of episodes of emesis on the day after surgery or times to discharge.

CONCLUSIONS

Ondansetron is at least as effective as droperidol in reducing the frequency of emesis in children after strabismus repair, and it did not shorten times to discharge home. The low number of patients in our study may have masked a difference in effect between the two groups. The clinician should decide whether the increased cost of ondansetron justifies its use over other antiemetics.