|Year : 1971 | Volume
| Issue : 3 | Page : 117-129
A study of effects of premedication with Pethidine, Largactil and Siquil used individually and in different combinations in cataract surgery
S. C. B. Medical College, Cuttack, India
S. C. B. Medical College, Cuttack
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Das B. A study of effects of premedication with Pethidine, Largactil and Siquil used individually and in different combinations in cataract surgery. Indian J Ophthalmol 1971;19:117-29
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Das B. A study of effects of premedication with Pethidine, Largactil and Siquil used individually and in different combinations in cataract surgery. Indian J Ophthalmol [serial online] 1971 [cited 2020 Aug 5];19:117-29. Available from: http://www.ijo.in/text.asp?1971/19/3/117/34979
| Introduction|| |
The most common type of intraocular surgery undertaken extensively by an ophthalmic surgeon is cataract extraction. Lack of co-operative response of the patient, nausea and vomiting both during and after operation have been responsible for a number of complications. The operation is easily accomplished and operative and postoperative complications are reduced to a minimum, if the patient is subjected to proper anaesthesia and akinesia with suitable preoperative medication.
Many workers have discussed freely about choice of local or general anaesthesia in ocular surgery and the merits and demerits of each, but majority have opined in favour of local anaesthesia especially for cataract surgery. In the United States, 90% of opthalmologists use local anaesthesia (Atkinson  1961), and in England, the figure appears to be 80% (Zorab, 1961,), whereas in India almost all cataract surgery is done under local, unless it is contraindicated.
There has been an essential need for preoperative medication in order to achieve the relaxed state of the patient both mental and physical. More attention is being given now than before on use of sedatives like phenothiazine derivatives and analgesics like pethidine as preoperative medicaments in cataract surgery in addition to barbiturates which though reported by different workers, requires proper evaluation. It was felt essential to have a deeper knowledge and a more comparative idea about the merits and demerits of different drugs used individually or in combination. The present work has been carried out to study the effects of pethidine (meperidine hydrochloride), Largactil (Chlorpromazine) and Siquil (triflupromazine) used individually and in different combinations like pethidine with largactil and pethidine with siquil as preoperative medicaments in cataract surgery.
| Material and Method|| |
The present work was carried out on 150 patients, who were admitted to the S. C. B. Medical College Hospital, Cuttack for cataract extraction. Cases selected were usually elderly having senile mature cataract, although a very few had complicated or traumatic cataract or cataract with glaucoma. In all these cases, however, an attempt was made to deliver the lens either intracapsularly or extracapsularly.
Preliminary measures :
On admission, the type of cataract, any gross systemic disorders and ocular defects other than cataract were noted. Pulse, respiration, blood pressure (B.P.), intraocular pressure (I.O.P.) were also recorded. Prior to admission, routine examination of urine and conjunctival smear were made. Besides, an attempt was made to search for any focus of infection in the teeth, throat, accessory sinuses or lacrimal sacs and appropriate treatment given when sepsis was detected in such foci.
In the evening previous to date of operation, the eye for operation was properly cleaned with antiseptic lotions and dressings as usual and a tablet of dial or Luminal was given to the patient at bed time.
On the morning of the operation, after the usual preparations for surgery, when the patient was brought in the operation theatre, anethaine(1%) solution was instilled into the conjunctival sac three times, at 5 minute intervals.
For a comparative study, the patients were divided into 6 groups of 25 each, who were given intramuscular premeditation 20 to 30 minutes before operation as follows:
1. Group I-Pethidine (100mg)
2. Group II-Largactil (50 mg)
3. Group III-Siquil (5 mg)
4. Group IV-Pethidine (50 mg) Largactil (25 mg)
5. Group V-Pethidine (50mg)
Siquil (2.5 mg)
6. Group VI-Treated as control group did not get any premedication with the above drugs.
Next, ciliary block was effected by retrobulbar novocaine infiltration as usual. Akinesia of orbicularis oculi was usually done by O'Brian's method. In a few cases, where the response was not adequate, van Lint method was applied.
Now, prior to the operation, the patient's pulse, respiration, B. P. were recorded. I.O.P. was recorded twice i.e. once before giving retrobulbar injection and once after this, in order to note the drop of I.O.P. after the retrobulbar injection.
After applying lid sutures and a superior rectus stitch, an upper corneal section was made with Graefe's knife in each case. In some cases, a broad peripheral iridectomy was done. The delivery of lens was made either extracapsularly or intracapsularly. The latter was usually attempted by Arruga's capsule frorceps applied on the lower part of capsule or occasionally by the Smith Indian method of expression. In some cases, during delivery of lens, the capsule ruptured, which could not be recovered and the lens was extracted by expression and recorded as "failed intracapsular". Vectis extraction was done in those cases, where indicated. In those cases, where prolapse of vitreous had occurred necessary toiletting was made. Before closing the eye, iris was reposited and some antibiotic drops or ointment put. In no case, however, corneal sutures had been given. Finally, both the eyes were covered with sterilised pads and bandage.
During operation, behaviour of the patient with regard to the following points were noted e.g. apprehension, relaxation, co-operation, restlessness, delirium, drowsiness, pain during giving retrobulbar injection, lid stitches or sup. rectus stitches and any other complaints like dryness of throat, tachycardia etc. No quantitative change in behaviour was recorded, the behaviour being studied clinically. Also complications like conjunctival haemorrhage, vitreous prolapse and intra-ocular haemorrhage if any, were noted.
Post operative measures-
A record of the following was made in each case thrice (i.e. between 2 to 3 hours, 6 to 9 hours, and 24 hours after operation) viz. pulse, respiration, B.P., behaviour responses as above, pain in the eye, sleep, nausea and vomiting, flatulence and retention of urine for which necessary treatment was given. At bed time, a hypnotic tablet was usually given to each patient.
Ocular complications like prolapse of iris and vitreous, nonformation of anterior chamber and intraocular haemorrage were also recorded for the first 3 days after the operation.
| Observations|| |
Mean results of pulse, respiration and B.P. on admission, after premeditation and before operation and after operation have been shown in [Table - 1],[Table - 2],[Table - 3] respectively. Mean results of I.O.P. on admission, after premedication and before and after retrobulbar infiltration have been shown in [Table - 4].
Behaviour responses and complications during operation have been indicated in [Figure - 1],[Figure - 2] respectively.
Behaviour responses and complications after operation have been shown in [Table - 6] respectively.
| Discussion|| |
Out of 150 cases, 60% were males and 40% were females. The age group varied from 20 to 70 years. Maximum cases (80%) studied belonged to the age group varying from 40 to 70 years. In 33.3% cases; clinically anaemia was observed, which was not likely to have any effect on premedication and operation.
Now comparing the results obtained with regard to chances in pulse, respiration, B.P., I.O.P., type of cataract extraction, behaviour response, operative and postoperative complications in the six different groups of patients. An idea about the efficacy of different types of premedication can be obtained.
Pulse and Blood Pressure:
There has been an average increase of pulse rate just before operation in all the six groups, although it was minimum in the control group. It returned to about normal level in 2 to 3 hours after operation and showed slight increase again in 6 to 9 hours, which became normal 24 hours after operation [Table - 1].
An average fall in B.P. both systolic and diastolic before operation was detected in all the first 5 groups although most marked in groups IV and V whereas in the control group, a small rise of systolic pressure only was observed. The B.P. in the first 5 groups reached practically normal level within 6 to 9 hours after operation, whereas in Group VI, systolic pressure came to normal gradually within 24 hours after operation [Table - 2]. Again, a fall in systolic pressure of 10 to 30 mm Hg was observed in 100% cases in groups IV and V and 80%, 44% and 52% of cases in groups I, II and III respectively and 20% cases only in Group VI.
The findings on pulse and B.P., as stated above, in Groups III and V are similar to these reported by Agarwal, Sharma and Chandra  the slight increase in percentage of cases and decrease in duration of effect in the latter being quite likely due to intravenous administration of drugs. Hanji  also found transient tachycardia in some patients due to Siquil, given intravenously as premedication.
Nutt and Wilson  have stated that the effect of pethidine and largactil on B.P. is not so marked in normotenasive patients and that the greater the degree of hypertension, the more precipitous the fall. In 2 out of their 80 cases, the preoperative systolic B.P. was over 250 mm Hg, which came down to between 70 to 90 mm Hg. as a result of largactil/ pethidine mixture given intravenously, slowly 15 minutes prior to operation, remained low for over 3 hours postoperatively and returned to preoperative level in 12 hours. In the present series 8 cases had quite high B.P. on admission, but their B.P. was reduced gradually by hypotensive drugs like serpasil, so that on the day of the operation it reached near about normal level. And as such, not a single case of serious hypotension was noticed as a result of premeditation with drugs, which were again administered intramuscularly. But moderate hypotension of 10 to 30 mm Hg. was noticed in some cases as stated above. This shows the potentiating action of phenothiazine group of drugs on pethidine, so far as lowering of B.P. is concerned, which again confirms the findings of Rolason and Hough  Moderate hypotension is certainly beneficial for cataract surgery, as it causes less bleeding and helps in reducing I.O.P.
Severe hypotension requiring treatment in head-down position and administration of vasopressor drugs, was observed by Harly and Mishler  in 2 cases out of 100 cataract extractions and by Ingram and Armstrong  in 42 out of their series of 500 cases of intraocular surgery as a result of pethidine-largactil premedication. In the present series, there has never been any occasion for coming across such risks, requiring undertaking of emergency measures as stated above. However, sufficient care was taken in transportation of the patient in a perfect lying down position from the operation theatre to the ward and further the doses of different sedatives used for premedication, although constant for different groups of cases, were quite moderate and rather towards the low side than high. Thus the incidence of serious hypotension was nil.
The average increase of respiration rate as observed before operation in the first 5 groups is practically negligible [Table - 3]. Ingram and Davison  have warned about the possibility of respiratory depressant effect of pethidine, especially when given with other drugs intravenously, like promazine and phenergan etc. for causing heavy sedation for cataract surgery, especially in cases with chronic bronchitis.
In the present series, not a single case of respiratory depression was seen. There were altogether 5 patients in the series with pulmonary disease like bronchitis and asthma, of whom one belonged_ to Group IV and V each and 3 others to the control group. None of them also developed any untoward respiratory complication during or after surgery. This is quite likely due to the fact that the dose was quite moderate and never large so that it exerted inappreciable effect on respiration. Moreover, when it is combined with phenothiazine group of drugs like largactil or siquil the latter increase the respiratory rate depressed by pethidine. Besides, the route of administration of drugs used in the present series was intramuscular and not intravenous.
From the mean result of I.O.P. [Table - 4] it is seen that the effect of retrobulbar injection in reducing the I.O.P. is somewhat similar in each group, i.e. a drop varying from 3 to 4 mm Hg. but the reduction in I.O.P. is marked just before operation, when the premedication is effected with pethidine combined with either largactil or siquil (Groups IV and V) i.e. 11 and 12 mm Hg respectively. Again, the fall of I.O.P. by 10 mm or more before operation was noted in majority of cases (92%) in group V and Group IV and in minimum number of cases (16%) in group II.
Agrwal et al  found that I.O.P. fell by an average of 7.5 mm Hg due to premeditation with chlorpromazine alone, 3 mm Hg due to curare alone and 9 mm Hg due to combination of chlorpromazine curare and acetazolamide and that in the chlorpromazine series some patients showed an average rise in tension of 11.7 mm Hg, whereas this did not occur in any of the other series. In the present work, the average fall in I.O.P. as obtained in Group II is similar to the above finding but in no case there was rise in I.O.P. The marked lowering of I.O.P. due to premedication by combination of pethidine with largactil or siquil, as found in the present work has also been noted by Nutt and WiIson  and Kenny 
Behaviour responses during operation:
These have been shown in [Figure - 1] from which it is noted that good behaviour responses are observed in cases belonging to groups IV and V. In these groups, good relaxation, cooperation, good sleep and calmness were observed in majority of cases, whereas the adverse effects like apprehension, restlessness, delirium, complaint of pain during giving stitches and other side complaints were observed in a minimum number of cases. Out of these 2 groups, effect of pethidine with siquil (Group V) was better. As regards premeditation with individual drugs, corresponding to groups I, II and III, there were variations in behaviour responses and it was observed that pethidine was superior to largactil and siquil and between largactil and siquil, siquil appeared to be better. The effects of pethidine and siquil are found practically similar, so far as apprehension, relaxation, cooperation, restlessness and side complaints are concerned, but with pethidine, the patient feels more drowsy, does not become delirious and complains less of pain when stitches are applied. Largactil differs from siquil in that it causes more restlessness and dryness of throat.
In the control group, relaxation co-operation and drowsiness were found in least number of cases, whereas apprehension, restlessness and pain during giving lid stitches etc. were well-marked. No case had delirium and side complaints were negligible.
Fishof  studying the effect of intravenous injection of meperidine hydrochloride (Demerol) alone in 108 cataract extractions in doses of 25, 50, 75 or 100 mg, obtained relaxation, semihypnosis and cooperation of the patients. but he, does not recommend the intravenous use of the drug indiscriminately, which should be confined to those displaying a tense and irritative psychomotor temperament. In the present series, meperidine hydrochloride (pethidine) alone was given in a dose of 100 mg. (Group I) and the effects with regard to above points were quite satisfactory.
Better effects on behaviour responses due to combination of chloropromazine with pethidine or other drugs like curare, acetazolamide etc. than due to chlorpromlazine alone, have been noted by Byerley, Murray, Winter and Victols  Burn, Hopkin, Edwards and James  , Karkashian Hunt and Whishler  . Agarwal, Gupta and Malik  , which correspond to those seen in the present series i.e. in Groups II and IV. Of course, side complaints like dryness of mouth etc. were marked in cases receiving largactil either alone or in combination with pethidine.
Agarwal et al  and Rehatgi  have found quite good effect of siquil on behaviour responses. The former noticed better effects when siquil was combined with pethidine and that side effects like dryness of mouth, tachhycardia etc. were maximum when it was given intravenously and minimum when given orally. In the present series, siquil was administered intramuscularly and found to be quite effective as a potent tranquiliser and more so, when combined with pethidine. Side effects were seen in a very few cases also i.e. 12% in contradistinction to largactil premedication, where these were seen in 56% cases.
Complications during operation:
Operative complications like conjunctival haemorrhage and prolapse of vitreous as obtained in percentage of cases have been shown in [Figure - 2].
As to conjunctival haemorrhage, it occured in a maximum number of cases (40%) in the control group and least in Groups I, IV and V.
Vitreous prolapse occured maximum (36%) in the control group and least in groups II, IV and V (12% in each).
In no case, however, there was intraocular haemorrhage.
Burn et al  found minimal conjunctival bleeding when premedication was done with pethidine combined with chlorpromazine and promethazine. Agarwal et al  noted that the incidence of conjunctival bleeding and vitreous prolapse was less when chlorpromazine alone was given but least when it was combined with curare and acetazolamide which also lowered the I.O.P. to a marked extent, from which it is evident that more the reduction in I.O.P., lesser will be the incidence of vitreous prolapse.
In the present series as well, incidence of conjunctival bleeding was much less when pethidine was combined with largactil or siquil, than when the latter were used alone. With pethidine alone also, there was minimum bleeding. This shows that pethidine is helpful in this respect.
As to the incidence of vitreous prolapse, it was maximum in the control group, in which reduction of I.O.P. was least and was much less when combination of pethidine with largactil or siquil was given, in which the fall in I.O.P. was marked. Rehatgi  has reported that the incidence of vitreous prolapse was reduced to 1 % with premeditation with siquil 20 mg given intramuscularly, but in the present series, the result with siquil alone has not been encouraging, as the incidence of vitreous prolapse has been 20%. Of course, the dose of siquil was only 5 mg. instead of 20 mg.
Behaviour responses in post-operative period:
These have been shown in [Table - 5] and some have also been represented graphically [Figure 3].
Percentage of casess showing restlessness within 2 to 3 hours [Figure 3]A and 6 to 9 hours after operation has been quite low in the first 5 groups as compared to the control group.
None, however, was found restless 24 hours after operation. Restlessness was least marked in cases, who were given siquil either alone or in combination with pethidine, showing that it is somewhat more effective than largactil or pethidine so far as sedation is concerned. Rohatgi  and Frank and Coyle  have also found good effect of siquil in this respect.
It was noted in only 2 cases (one each in Group II and III) who were, of course, extremely nervous in temperament and were also delirious during operation. Delirium continued in one of Group II up to 2 to 3 hrs and in the other of group III up to 6 to 9 hrs after operation.
Pain in Eye:
It was complained of by many cases within 2 to 3 hours [Figure 3]B and by some within 6 to 9 hours after operation. None, however, complained of the same 24 hours after operation. This complaint was made most in cases belonging to control group (96%) and least in cases in Group V (16%) within 2 to 3 hours after operation. This persisted upto 6 to 9 hours after operation in maximum number of cases in the . control group (80%) in a moderately high number in group II (52 0 %) and least in Groups I, III and IV i.e. 28%, 20% and 20% respectively, whereas no case belonging to group V complained of the same then.
Best sleep was obtained in cases receiving pethidine. Largactil or siquil was not so effective in this respect. However, a combination of pethidine with either of these, especially with siquil (Gr. V) was quite satisfactory [Figure 3]C.
Nausea and Vomiting:
Percentage of cases in the whole series showing these complications was quite negligible. This is quite likely due to the attention to the factors like use of pethidine and barbiturate rather than morphine, local anaethesia rather than general and early attention to post operative abdominal distension as observed by Hanno  (1965) at Wills Eye Hospital. In Gr. I 2 cases complained of nausea only within 2 to 3 hours and in Gr. IV, only one case had nausea and vomited twice within 6 to 9 hours after operation and in control group, out of 2 cases one complained of only nausea for 2 to 3 hours after operation and the other nausea throughout for the day and vomited once in the morning 24 hours after operation. No case in any of the other groups had either nausea or vomiting [Table - 5]. Thus in this respect largactil has been found superior to siquil, which corraborates with the observations of Hanji  (1963).
It was noted in moderate number of cases within 6 to 9 hours after operation in all the groups except Group V and most marked in group I and control group (32% each) [Figure 3]D Only in one case in Gr. I, it was noted 24 hours after operation.
Harley and Mishler  have found from their study on 200 cataract cases that abdominal distension was uncommon and they believe that since the patients are allowed to sit up immediately postoperatively and allowed to turn on the unoperated side, this complication is markedly reduced. If this be so, the cause of increased incidence of abdominal distension in the present series is obvious, since cases in these series were not allowed to sit up for 3 to 4 days after operation.
Retention of urine:
Agarwal et al  did not find post-operative retention of urine in any of their cataract extraction cases receiving chlorpromazine alone, acetazolamide alone and combination of acetazolamide, curare and chlopromazine, except in very few cases receiving curare alone. But in the present series, quite a large number developed this complication usually within 6 to 9 hours after operation, most marked in control group and in those receiving pethidine (i.e. Gr. I) [Figure 3]E. With siquil alone, this complication was least marked; in no case, however, it was seen 24 hours after operation.
These have been shown in [Table - 6] from which it is seen that incidence of prolapse of iris and vitreous and non-formation of anterior chamber and intraocular haemorrhage in form of hyphaema, although low was more marked in Gr. I, II, III and in the control group and least in Group No. IV and V: This occured in some cases, who showed post-operative restlessness, vomiting and retention of urine. Of course, post-operative complications as seen after 2nd day of operation need not be attributed to the effects of pre-medication, which certainly never last for more then 24 hours, but in certain cases the latter may be indirectly responsible, as the complications seen on 2nd day of operation may continue to be present the next day.
| Summary and Conclussions|| |
1. Study of pre-operative medication in cataract surgery under local anaesthesia has been made on 150 cases, who were divided into 6 groups of 25 each. The first three received pethidine, largactil and siquil alone, the fourth one, pethidine and largactil and the fifth, pethidine and siquil. Group VI was treated as control.
2. The effects of these premedicaments on pulse, respiration, blood pressure, intraocular pressure, behaviour responses of the patients and operative and post operative complications have been studied.
3. With regard to premedication, the effects of combination of pethidine with largactil or siquil were found to be better than individual drugs. Finally, between two types of combined premeditation, pethidine with siquil was found superior to pethidine with largactil.
I am grateful to Dr. M. C. Misra, D. O. M. S. (London), Retired Professor and Head of the Department of Ophthalmology, S.C.B. Medical College Cuttack, who was my guide.
| References|| |
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[Figure - 1], [Figure - 2]
[Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5], [Table - 6]