Alexandre Roth de Oliveira, MD, MSc, Roth & Roth Anesthesia Clinic
Port Alegre, Brazil
The evolution of ophthalmologic surgery brings back the popularity of regional anesthesia techniques. The search for the ideal anesthetic approach have been based in safety and efficacy basis. Peribulbar medial canthus single was successfully attempted but not with a less traumatic needle.
A technique presentation of the peribulbar medial canthus single approach using a 13x0x45mm needle is detailed and advocated as an alternative to perform ophthalmic surgeries.
Sonali Raman, MBBS, DA, Sankara Nethralaya
Tamilnadu Chennai, India
Currently used methods of sedation for ophthalmic surgeries such as Propofol or Midazolam have their limitations. Dexmedetomidine (DEX) is a selective α-2 adrenergic agonist that has been used clinically for its sympatholytic, analgesic, and sedative properties. We report on 5 patients with difficult airways associated with other comorbidities who underwent successful ocular surgery under regional anesthesia with Dexmedetomidine as sedative. Dexmedetomidine was used to provide a moderate level of conscious sedation without causing respiratory distress or hemodynamic instability.
Sujatha Ravichandran, DA, DNB, Sankara Nethralaya
Tamilnadu Chennai, India
During Jan 2017-Dec 2017, 8 patients were recruited in the study. Patients who could benefit with a nasopharyngeal airway were identified during the preoperative evaluation. Selected patients were sedated withPropofol and nasopharyngeal airway was inserted prior to Peribulbar anesthesia, draping and surgery. The ease of insertion of nasopharyngeal airway, feasibility of monitoring ETCO2 with nasopharyngeal airway and Surgeon, patient satisfaction was assessed. Any procedure related complication was also noted. We observed that nasopharyngeal airway insertion is a safe and effective procedure in selective group of patients, for ophthalmic surgeries under local anesthesia with sedation.
Zachary Janik, Johns Hopkins School of Medicine
We present the case of a 66 year old woman with a complex past medical history notable for granulomatosis with polyangiitis, Graves’ disease (status post thyroidectomy), provoked pulmonary embolism, type IV paraesophageal hernia (status post repair), and chronic kidney disease who experienced substernal chest pain with normal sinus rhythm and ventricular bigeminy on EKG several hours after undergoing right inferior and medical rectus muscle recession for correction of hypotropia and esotropia. She described prior substernal chest pain and tightness exacerbated by eating and stress, including 10/10 chest pain the night prior to surgery after an emotional conversation with her daughter. Her cardiac workup was unremarkable, but a CTA chest revealed concern for an esophageal etiology (stricture vs. spasm). An esophagoduodenoscopy (EGD) and manometry were normal. A chemical induced nausea and emesis (CINE) test was performed, which revealed evidenced of esophageal spasm. She was started on diltiazem and discharged home without issue. We explore the important and interesting symptom of post-operative chest pain and its non-cardiac etiologies.
Zachary Janik, Johns Hopkins School of Medicine
We present the case of a 54 year-old male with past medical history of alcohol abuse, cigarette smoking, and bilateral cataracts who was undergoing extraction of the left cataract when his heart rate increased to >160 bpm and an EKG showed a supraventricular tachycardia after a sub-Tenon’s block using lidocaine. He soon became hypotensive, requiring administration of phenylephrine and esmolol, with resolution but continued tachycardia responsive to adenosine. We believe this is a rare case of oculocardiac reflex tachyarrhythmia secondary to the pressure produced by the sub-Tenon’s block. We explore the differential diagnosis and review the literature of this fascinating topic.
George Dumas, MD, University of Alabama at Birmingham
Objective: To determine the prevalence, severity, and predictors of autonomic dysfunction and associated hemodynamic instability in retinal surgery patients.
Methods: This is a prospective cohort study of patients undergoing elective retinal surgery at a large academic center that received preoperative non-invasive autonomic nervous system (ANS) testing. Patients were observed for presence/degree of intraoperative autonomic dysfunction (stage 0-6) and hemodynamic compromise. Hemodynamic compromise was indicated by vasopressor or atropine use and major adverse cardiac event. Severe hypotension was defined by use of vasopressor drip and/or epinephrine bolus. Multivariate regression analysis was used to identify risk factors associated with severe autonomic dysfunction.
Results: Over a 1.25 year period, 168 patients underwent retinal surgery; 29 (17%) had severe autonomic dysfunction (stage6/cardiac autonomic neuropathy) with severe hypotension. There was a statistically significant greater prevalence of diabetes (93% vs. 50%, p<0.001) and cardiac disease (CHF p=0.027, CAD p=0.050, pre-op beta-blocker use p=0.013) in patients with severe autonomic dysfunction compared to those with no or less severe autonomic dysfunction. No severe intraoperative hypotension was observed in any regional anesthesia+ monitored anesthesia care (MAC) cases. For general anesthesia (GA) cases, the incidence of severe hypotension was significantly greater in patients with severe autonomic dysfunction compared to patients with no or a lesser degree of autonomic dysfunction (p= 0.050). Conclusion: Amongst patients undergoing retinal surgery, diabetes, CHF, CAD, and pre-op beta-blocker use are significant risk factors associated with development of severe autonomic dysfunction (stage6/cardiac autonomic neuropathy). Severe autonomic dysfunction is predictive of severe hypotension intraoperatively during GA. If GA is considered in severe autonomic dysfunction, severe hypotension can be anticipated and closely monitored or avoided by choosing regional anesthesia+ MAC. Preoperative autonomic testing and risk factor assessment can identify high risk patients, abnormal protein deposits and can manifest locally or systemically (1). Diagnosis is confirmed with biopsy and histological exam of the affected organ. We present two cases of patients who were incidentally diagnosed with amyloidosis after the removal of the tape used for ocular protection during anesthesia resulted in bilateral eyelid skin detachment. Case Reports: Case 1. A 53-year-old man with multiple myeloma presented for femur intramedullary nailing. After anesthetic skinduction, clear tape (3M Transpore ™) was placed over the patient’s eyelids for ocular protection. When removed at the end of the procedure, the tape caused upper eyelid in detachment, resulting in bilateral cutaneous abrasions (Figure 1A). An ophthalmology consult revealed abnormal eyelid pigmentation, so the skin specimen was sent for dermatopathology workup. Recommended therapy for the abrasions was bacitracin ophthalmic ointment QID. A positive Congo red stain of the tissue was consistent with the diagnosis of amyloidosis (Figure 2). The abrasions improved with one week of ointment application. Case 2. A 63-year-old man with multiple myeloma presented for total thyroidectomy. Upon awakening from anesthesia, the patient had significant ecchymosis over both right and left eyelids. Patient stated he has a history of bruising and bleeding easily ever since his diagnosis of multiple myeloma and primary amyloidosis of light chain type. Discussion. Overall, the incidence of skin injury caused by medical adhesive tape is 15.5% (2). Cutaneous manifestations of systemic amyloidosis occur in 30-40% of patients (3), therefore it is important to recognize the potential harm of adhesive use in this patient population. Amyloid angiopathy results when amyloid is deposited in blood vessels, resulting in friable capillaries that can rupture with minimal trauma such as rubbing of the eyelids, sneezing, or coughing. Recommendations for ocular protection particularly for patients with known amyloidosis include ocular lubrication and covering the eyelids with gauze before taping (4). Avoiding deep Trendelenburg position, Valsalva maneuvers, and eye manipulation can also help minimize the risk of trauma (3). It is also important to ask the patient if they have any history of eyelid bruising during the anesthetic patient interview to prevent this complication from occurring.