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Engelen N, Heindl LM, Oppitz F, Rokohl AC, Schumacher C, Leister N. [Pain therapy in children following ophthalmic surgery]. DIE OPHTHALMOLOGIE 2023; 120:711-716. [PMID: 37326853 DOI: 10.1007/s00347-023-01884-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/26/2023] [Indexed: 06/17/2023]
Abstract
Pain following eye surgery is often described as being relatively moderate; however, there are also procedures that lead to a pronounced pain experience. Particularly in pediatric patients, pain therapy is often insufficient due to a lack of knowledge and fear of complications. These individual and organizational deficits lead to unnecessary discomfort for children and parents. Each institution providing surgical treatment must have pain management concepts in its portfolio for the appropriate age groups. This includes a child-oriented setting, age-appropriate information, systematic pain assessment, and pain protocols. Pain management should be planned prior to surgery and individually adapted as it progresses. Children have a right to a perioperative course with low stress and pain.
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Affiliation(s)
- Natascha Engelen
- Praxis für Kinderanästhesie, Nürnberg, Deutschland
- Klinik für Anästhesiologie und Intensivmedizin, Klinik Hallerwiese-Cnopfsche Kinderklinik, Nürnberg, Deutschland
| | - Ludwig M Heindl
- Klinik für Augenheilkunde, Medizinische Fakultät und Uniklinik Köln, Universität Köln, Köln, Deutschland
| | - Francesca Oppitz
- Divisie Vitale Functies, Wilhelmina Kinderziekenhuis (WKZ), Universitair Medisch Centrum Utrecht, Utrecht, Niederlande
| | - Alexander C Rokohl
- Klinik für Augenheilkunde, Medizinische Fakultät und Uniklinik Köln, Universität Köln, Köln, Deutschland
| | - Christine Schumacher
- Klinik für Anästhesiologie und Operative Intensivmedizin, Medizinische Fakultät und Uniklinik Köln, Universität Köln, Kerpener Str. 62, 50937, Köln, Deutschland
| | - Nicolas Leister
- Klinik für Anästhesiologie und Operative Intensivmedizin, Medizinische Fakultät und Uniklinik Köln, Universität Köln, Kerpener Str. 62, 50937, Köln, Deutschland.
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Poe E, Bosley R, Steele R, Chesnut C. Trigeminocardiac Reflex: A Review and Key Implications to Dermatologic Surgery. Dermatol Surg 2023; 49:654-658. [PMID: 37134251 DOI: 10.1097/dss.0000000000003808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
BACKGROUND The trigeminocardiac reflex is a common but underreported occurrence that can vary from benign to life threatening. This reflex can be elicited by placing direct pressure on the globe of the eye or from traction of the extraocular muscles, stimulating the trigeminal nerve. OBJECTIVE To provide a review of potential stimuli for the trigeminocardiac reflex within dermatologic surgery and to discuss management options for the treatment of the trigeminocardiac reflex. METHODS PubMed and Cochrane were used to identify articles and case reports that established scenarios in which the trigeminocardiac reflex was provoked and subsequently how the reflex was managed. RESULTS Within the field of dermatologic surgery, the trigeminocardiac reflex can be stimulated during biopsies, cryoablations, injections, laser treatments, Mohs micrographic surgery, and oculoplastic interventions, most often occurring in an office setting. The most common presentations include significant bradycardia, hypotension, gastric hypermobility, and lightheadedness. The most definitive treatment is cessation of the inciting stimulus, monitoring, and symptomatic management. Glycopyrrolate and atropine are common treatments for severe, intractable cases of the trigeminocardiac reflex. CONCLUSION The trigeminocardiac reflex, while underreported and underrepresented in dermatologic literature and dermatologic surgery settings, should be considered in the setting of bradycardia and hypotension during dermatologic procedures.
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Affiliation(s)
- Emily Poe
- Washington State University College of Medicine, Spokane, Washington
| | - Rawn Bosley
- Chesnut MD Cosmetic Surgery Fellowship, Spokane, Washington
| | - Robert Steele
- Chesnut MD Cosmetic Surgery Fellowship, Spokane, Washington
| | - Cameron Chesnut
- University of Washington School of Medicine, Seattle, Washington
- Chesnut MD Cosmetic Surgery Fellowship, Spokane, Washington
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Hydroxyzine Dihydrochloride Premedication Is a Necessity for Pediatric Patients Undergoing Strabismus Surgery: An Observational Prospective Clinical Trial. J Ophthalmol 2022; 2022:4137144. [PMID: 36189149 PMCID: PMC9519320 DOI: 10.1155/2022/4137144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 08/26/2022] [Accepted: 09/02/2022] [Indexed: 11/24/2022] Open
Abstract
Objective In this single-blind, observational prospective clinical trial, we aimed to determine and compare the effects of premedication with hydroxyzine plus midazolam and midazolam alone on the incidence of oculocardiac reflex (OCR). Methods Forty-five patients were divided into three groups. Group M received 0.5 mg/kg midazolam alone, Group H received 0.5 mg/kg hydroxyzine plus 0.5 mg/kg midazolam, and Group HM received 1 mg/kg hydroxyzine plus 0.5 mg/kg midazolam. The Ramsay Sedation Scale (RSS), the heart rates (HR1: after induction of anesthesia; HR2: before retraction of orbital muscle; and HR3: right after retraction of orbital muscle), the muscles with OCR, and the incidence of OCR (20% decrease of the HR right after the traction) were recorded and compared between the three groups. Results The mean HR1, HR2, and HR3 values were significantly increased (p=0.002, p < 0.001, p < 0.001) and the incidence of OCR (p=0.004) was significantly decreased in Group H and in Group HM (for all, p < 0.01) compared to Group M. The most common orbital muscle in which OCR occurred was the rectus medialis. Conclusion Premedication with a combination of 0.5 or 1 mg hydroxyzine with 0.5 mg midazolam significantly reduced the incidence of OCR compared to premedication with midazolam alone. This study was registered on https://clinicaltrials.gov/ with number NCT03806270.
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Lenhart PD, Lambert SR. Current management of infantile cataracts. Surv Ophthalmol 2022; 67:1476-1505. [DOI: 10.1016/j.survophthal.2022.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 03/13/2022] [Accepted: 03/14/2022] [Indexed: 10/18/2022]
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An Opioid-free Anesthesia Protocol for Pediatric Strabismus Surgery: A Quality Improvement Project. Pediatr Qual Saf 2021; 6:e462. [PMID: 34476314 PMCID: PMC8389911 DOI: 10.1097/pq9.0000000000000462] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 04/02/2021] [Indexed: 01/05/2023] Open
Abstract
Introduction: This quality improvement (QI) project tracks a series of 2 Plan-Do-Study-Act (PDSA) cycles as we standardized and refined an ambulatory pediatric anesthesia strabismus protocol. We aimed to provide effective pain relief, reduce postoperative nausea and vomiting (PONV) rates, and be cost-efficient while minimizing perioperative opioids over 5 years. Methods: We used statistical process control (SPC) charts to analyze real-world data captured from the medical record. We chose the following outcome and process measures to evaluate effectiveness: postoperative morphine rescue rate, maximum pain score in the postanesthesia care unit (PACU), and PONV rescue rate. We also used 2 balancing measures: postoperative length of stay (LOS) and total anesthesia time. We standardized our anesthesia protocol for our first PDSA cycle (April 2017) by removing intraoperative intravenous acetaminophen and utilizing fentanyl only. For the second PDSA cycle (January 2019), we replaced intraoperative fentanyl with dexmedetomidine. Results: There was a total of 325 pediatric strabismus repair surgeries performed between April 2015 and July 2020. There was no special cause variation detected in the SPC charts for the family of measures chosen to measure effectiveness: postoperative morphine rescue rate, maximum pain score in the PACU, or the PONV rescue rate. The PONV rescue rate was 0 with the removal of opioids. Also, there was no special cause variation for the balancing measures: postoperative LOS or total anesthesia time. Conclusions: Throughout 2 PDSA cycles, this QI project enabled our team to standardize an opioid-free and cost-efficient anesthesia protocol for pediatric strabismus surgery over 5 years.
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Abstract
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.
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Affiliation(s)
- Robert W Arnold
- The Alaska OCR Study, Alaska Blind Child Discovery, Alaska Children’s EYE & Strabismus, Anchorage, AK, 99508, USA
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Arnold RW, Jansen S, Seelig JC, Glasionov M, Biggs RE, Beerle B. Anesthetic Impacts on the Oculocardiac Reflex: Evidence from a Large, Observational Study. Clin Ophthalmol 2021; 15:973-981. [PMID: 33716499 PMCID: PMC7944370 DOI: 10.2147/opth.s300860] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 02/09/2021] [Indexed: 01/16/2023] Open
Abstract
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. ![]()
Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use: https://youtu.be/KX3gZ_OguLA
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Affiliation(s)
- Robert W Arnold
- Alaska Children's EYE & Strabismus, Anchorage, AK, 99508, USA
| | | | | | - Mikhail Glasionov
- Department of Anesthesia, Alaska Regional Hospital, Anchorage, AK, USA
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Zhu Y, Yang S, Zhang R, Fan P, Yao G, Li J, Xie Z, Gan X. Using Clinical-Based Discharge Criteria to Discharge Patients After Ophthalmic Ambulatory Surgery Under General Anesthesia: An Observational Study. J Perianesth Nurs 2020; 35:586-591.e1. [PMID: 32855052 DOI: 10.1016/j.jopan.2020.04.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 04/11/2020] [Accepted: 04/21/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE To verify the feasibility of the clinical-based discharge (CBD) criteria and identify the reasons of long postanesthesia care unit length of stay (PACU-LOS) for ophthalmic ambulatory surgical patients under general anesthesia. DESIGN A prospectively observational study conducted at a tertiary eye center in China. METHODS Medical records were collected from patients admitted for strabismus ambulatory surgery under general anesthesia from September 2018 to March 2019. The patients were discharged home once met the CBD criteria based on a combination of the modified Aldrete's scoring system and Chung's Post-Anesthetic Discharge Scoring System. Postoperative complications were recorded in the PACU and within 24 hours after discharge. Multivariate logistic regression was applied to identify the factors relating to late discharges. FINDINGS All patients (N = 400) were safely and successfully same-day discharged home as none of the patients informed severe emergency events or unanticipated readmission. Nine displayed discharge delays mainly because of mild postoperative nausea and vomiting (PONV) although met the discharge criteria. About 85.5% of patients were discharged within a PACU-LOS of 150 minutes, 379 (94.8%) were within 180 minutes, and the cutoff time in PACU-LOS was 150 minutes. Multivariable analysis indicated that sevoflurane anesthesia and the presence of PONV were related to late discharges (PACU-LOS of greater than 150 minutes, all P < .05). CONCLUSIONS The CBD criteria can efficiently and safely guide the ophthalmic ambulatory surgical patients to discharge home on the same-surgery day, whereas sevoflurane anesthesia and the presence of PONV are associated with a relatively long PACU-LOS.
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Affiliation(s)
- Yanling Zhu
- State Key Laboratory of Ophthalmology, Department of Anesthesiology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Shiying Yang
- State Key Laboratory of Ophthalmology, Department of Anesthesiology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Rui Zhang
- State Key Laboratory of Ophthalmology, Department of Anesthesiology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Peiting Fan
- State Key Laboratory of Ophthalmology, Department of Anesthesiology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Guanjing Yao
- State Key Laboratory of Ophthalmology, Department of Anesthesiology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Jinfei Li
- State Key Laboratory of Ophthalmology, Department of Anesthesiology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Zhubin Xie
- State Key Laboratory of Ophthalmology, Department of Anesthesiology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Xiaoliang Gan
- State Key Laboratory of Ophthalmology, Department of Anesthesiology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China.
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Tan D, Xia H, Sun S, Wang F. Effect of ancillary drugs on sevoflurane related emergence agitation in children undergoing ophthalmic surgery: a Bayesian network meta-analysis. BMC Anesthesiol 2019; 19:138. [PMID: 31370793 PMCID: PMC6670177 DOI: 10.1186/s12871-019-0810-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 07/25/2019] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The comparative efficacy of ancillary drugs on sevoflurane related emergence agitation (EA) in children undergoing ophthalmic surgery remains controversial. METHODS The databases were retrieved in an orderly manner from the dates of their establishment to October, 2018, including PubMed, The Cochrane Library and Web of Science, to collect randomized controlled trials (RCT) of different anesthetic drugs combined with sevoflurane for ophthalmic surgery. Then a network meta-analysis was conducted using R and Stata 12.0 softwares. RESULTS The meta-analysis showed that, in reducing sevoflurane related EA, dexmedetomidine, ketamine, propofol, fentanyl, midazolam, sufentanil, remifentanil and clonidine were superior to placebo (P < 0.05). The network meta-analysis showed that the effects of ancillary drugs combine with sevoflurane in reducing risk of EA in children undergoing ophthalmic surgery was superior to placebo: dexmedetomidine (OR = 0.17, 95% CrI 0.12-0.22), ketamine (OR = 0.30, 95% CrI 0.11-0.49), propofol (OR = 0.24, 95% CrI 0.09-0.63), fentanyl (OR = 0.16, 95% CrI 0.08-0.56), midazolam (OR = 0.20, 95% CrI 0.09-0.40), sufentanil (OR = 0.27, 95% CrI 0.14-0.41), remifentanil (OR = 0.18, 95% CrI 0.08-0.54) and clonidine (OR = 0.14, 95% CrI 0.07-0.41). The SUCRA of placebo, dexmedetomidine, ketamine, propofol, fentanyl, midazolam, sufentanil, remifentanil, clonidine were respectively 0.26, 77.93, 27.71, 42.8, 69.43, 52.89, 59.83, 57.62 and 61.53%. CONCLUSIONS The effects of dexmedetomidine combine with sevoflurane in reducing risk of emergence agitation in children undergoing ophthalmic surgery was superior to other drugs.
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Affiliation(s)
- Dan Tan
- Editorial Office, Journal of New Medicine, Zhongnan Hospital of Wuhan University, No.169 Donghu Road, Wuchang District, Wuhan, 430071, Hubei Province, China.
| | - Haifa Xia
- Department of Anesthesiology, Institute of Anesthesia and Critical Care, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shujun Sun
- Department of Anesthesiology, Institute of Anesthesia and Critical Care, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Fuquan Wang
- Department of Anesthesiology, Institute of Anesthesia and Critical Care, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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