|Year : 2002 | Volume
| Issue : 3 | Page : 205-208
Peribulbar anaesthesia using a combination of lidocaine, bupivocaine and clonidine in vitreoretinal surgery
E Calenda, Jean Claude Quintyn, G Brasseur
Department of Anesthesia Reanimation, Centre Hospitalier Universitaire de Rouen, 1 rue de Germont, 76031, Rouen, France
Department of Anesthesia Reanimation, Centre Hospitalier Universitaire de Rouen, 1 rue de Germont, 76031, Rouen
Source of Support: None, Conflict of Interest: None
Purpose: The efficacy and safety of peribulbar anaesthesia was assessed using a combination of lidocaine, bupivacaine and clonidine during eye surgery. Methods: We prospectively studied 100 vitreo-retinal surgical procedures performed by several
surgeons. The exclusion criteria included age below 30 years and, axial length of the orbit above 28 mm. Peribulbar was performed using Hamilton's technique. A mixed anaesthetic solution of equal quantity of lidocaine 2% and bupivacaine 0.5% with clonidine (1mg/kg) was injected. Patients received a mean volume of 14.5 ml ± 3.5 of the mixture. Akinesia and analgesia were assessed
15 minutes later by the surgeon. Whenever required, supplemental lidocaine 2% (3 ml) by sub- Tenon infiltration was added by the surgeon. Supplemental injections were given only to patients who failed to develop analgesia. Results: The mean age of patients (male 52%, female 48%) was 66 years ± 10 (mean ± SD, range 44-90). The 100 surgical procedures were made up of vitrectomy ± gas ± silicone oil (22/100), vitrectomy and lensectomy (6/100), vitrectomy and epiretinal membrane ± laser coagulation ± gas ± silicone oil (35/100), scleral buckling or encircling ± gas (36/100), and cryosurgery ± gas (1/100). Analgesia was adequate throughout surgery without any supplementation in 85% of cases and with a sub-Tenon infiltration in 99%. Akinesia was complete in 84%, mild in 12% and absent in 4% of cases. The sub-Tenon injection was performed in 15% of cases. Three patients (3%) were agitated during surgery. No neurologic or cardiac complication was seen. In one patient, the systolic blood pressure decreased from 170 to 110 mmHg, 30 minutes after the institution of the peribulbar block. Conclusion: Our results show that peribulbar anaesthesia in the proposed mixture offers excellent analgesia in 85% of patients, and in 99% of the patients when supplemented by a subtenon injection. The current mixture of lidocaine, bupivacaine and clonidine is an excellent alternative to the previously used mixture etidocaine, bupivacaine and hyaluronidase for vitreoretinal surgery. However, a randomized controlled clinical trial is needed to prove the efficacy and safety of these results.
Keywords: Peribulbar anaesthesia, clonidine, local anaesthesia, vitrectomy, retinal detachment
|How to cite this article:|
Calenda E, Quintyn JC, Brasseur G. Peribulbar anaesthesia using a combination of lidocaine, bupivocaine and clonidine in vitreoretinal surgery. Indian J Ophthalmol 2002;50:205-8
|How to cite this URL:|
Calenda E, Quintyn JC, Brasseur G. Peribulbar anaesthesia using a combination of lidocaine, bupivocaine and clonidine in vitreoretinal surgery. Indian J Ophthalmol [serial online] 2002 [cited 2018 Jan 20];50:205-8. Available from: http://www.ijo.in/text.asp?2002/50/3/205/14785
Peribulbar anaesthesia is recognised to be a safe regional anaesthesia for most ophthalmic surgical procedures., Several anesthetic drugs are used in ophthalmology to perform local anaesthesia such as lidocaine, etidocaine and hyaluronidase, or lidocaine, bupivacaine and hyaluronidase, or lidocaine and bupivacaine without hyaluronidase, or more recently, mépivacaine or ropivacaine. We routinely performed peribulbar block with a mixture of etidocaine, bupivacaine and hyaluronidase for vitreoretinal surgery, but the rate of cardiac and neurologic complications was significant. Generalised epilepsy was encountered in two patients (0.66 %) and systolic blood pressure sharply dropped in four cases. Hence, we carried out a prospective study to assess the efficacy and safety of peribulbar anaesthesia using a combination of lidocaine, bupivacaine and clonidine in vitreoretinal surgery. In case of insufficient analgesia a sub-Tenon injection was administered.
| Materials and Methods|| |
After obtaining the approval of the hospital ethics committee and the informed consent of the patients, we prospectively studied 100 vitreoretinal procedures performed by several surgeons from January 1998 to October 2000.
Peribulbar anaesthesia for eye surgery was systematically proposed to patients over 30 years. The exclusion criteria included age below 30 years, axial length of the eye more than 28 mm (every retinal detachment was assessed by an ultrasound method), active ocular infection, mental retardation, patients refusing local anaesthesia, acute respiratory disease, when the decubitus position was impossible and when the surgeon expected prolonged surgery (≥ 2 hrs).
All patients received hydroxyzine (UCB Pharma SA) (0.5 to 1 mg/kg), or alprazolam (Pharmacia - Upjohn) (0.01 mg/kg) one hour before surgery. A short-acting drug (midazolam-Roche) 1 or 2 mg was administered 5 minutes before peribulbar anesthesia in patients who seemed very anxious. Assessment of anxiety level was completely subjective because we did not use any scale. The administration depended on the judgment of the anaesthesiologist.
Peribulbar anaesthetic injection was performed using Hamilton's technique by only one anesthesiologist experienced in that technique, and as described in our previous studies., The first percutaneous insertion of the needle (25 gauge, 35 mm long) was parallel to the orbital floor at the lateral aspect of the inferior orbital rim (maximal depth 25 mm), and the second (maximal depth 25 mm) at the level of the supraorbital notch. The injection was immediately stopped when the globe became subjectively tense. As soon as the globe became soft, the injection was started again until the globe was again tense. A mixed anaesthetic solution of equal quantity of lidocaine (Astra) 2% and bupivacaine (Astra) 0.5% with clonidine (Boehringer Ingelheim) (1 mg/kg) was injected. Pressure (30 mm Hg) was applied by an ocular cuff for 15 minutes.
Akinesia and analgesia were assessed by the surgeon 15 minutes later. Analgesia was considered to be perfect when the patient did not notice any pain (assessed by a visual analogue scale) by holding bulbar conjunctiva and lateral rectus muscle insertion. Akinesia was considered perfect when no movement was observed in all directions. Patients were encouraged to inform the surgeon if they experienced pain during the surgery.
Whenever required supplemental lidocaine (Astra) 2% (3 ml) by sub-Tenon infiltration was added by the operating surgeon in charge of the current procedure. Three different surgeons, all experienced in the technique, were involved in the 100 procedures. A buttonhole was fashioned through the conjunctiva and the Tenon's capsule 10 mm posterior to the limbus in the temporal superior quadrant. The lidocaine was then delivered to the posterior sub-Tenon space using a blunt cannula.
Supplemental injections were given only to patients who failed to develop analgesia. The efficacy of analgesia was graded by the anaesthetist and the surgeon as follows: grade 1-adequate analgesia throughout surgery without any supplementation; grade 2-adequate analgesia with sub-Tenon injection; and grade 3-inadequate analgesia despite the subtenon injection.
All patients received nasal oxygen throughout the procedure and were supervised by cardiac monitoring and pulse oxymeter. Other recorded variables included number of multiple procedures, volume and concentration and onset of analgesia, onset of pain during surgery, ocular and general complications, duration of surgery and duration of postoperative analgesia up to the end of the surgery.
| Results|| |
The onset of anaesthesia was 17 ± 5 minutes (range 10-40 minutes) and the duration of surgery was 98 ± 34 minutes (range 30-180 minutes). The mean age of patients (male 52%, female 48%) was 66 ± 10 years (range 44-90 years). The 100 surgical procedures are listed in [Table - 1].
| Local anaesthesia|| |
The absolute volume of the anaesthetic mixture was 14.5 ml ± 3.5 (range 8 - 24 ml). Obviously the volume related to body weight was 0.20 ml/kg ± 0.06 (range 0.07 - 0.37). These quantities represented 2 mg/kg ± 0.60 (range 0.7 3.7) of lidocaine and 0.5 mg/kg ± 0.15 (range 0.175 - 0.925) of bupivacaine. The volume seems high but the concentration of bupivacaine (0.5%) is lower than that used in the other countries (0.75%). [6,7] The efficacy of a drug is due to its concentration so if the concentration decreases the volume must be increased to obtain the same effect. The mixture was made up of an equal quantity of bupivacaine 0.5% and lidocaine 2% 1 mg/kg clonidine.
The dose of clonidine never exceeded 90 mg. Sub-Tenon infiltration was required in 15 % of patients either immediately before surgery (70 %) or during the surgery about 2 hours after the peribulbar injection (30 %).
| Analgesia and akinesia|| |
Efficacy of analgesia and akinesia are shown in Table 2. Analgesia was graded as follows: grade 1-adequate analgesia throughout surgery without any supplementation; grade 2 - adequate analgesia with sub Tenon injection and grade 3 - inadequate analgesia despite the sub-Tenon injection. Akinesia was considered as follows: complete - no eye movement in all directions; mildsome movements in one or several directions; and absent - complete mobility in all directions.
Adequate analgesia was obtained with peribulbar anaesthesia alone in 85 % of patients 15 minutes after injection and with a sub-Tenon infiltration in 99 %. But one patient experienced mild pain throughout the surgery in spite of a sub-Tenon infiltration and an opioid (nalbuphine) was necessary to relieve the pain. A mild orbicularis oculi muscle activity was encountered in 12 % and akinesia was totally absent in 4% of the patients. Complete akinesia was obtained in 84 % of patients.
| Complications|| |
In one patient general anesthesia was given before starting surgery, because the eye block did not result in sufficient analgesia, as the globe was severely inflammated. Neurologic complication was not seen in this series of patients. In one patient, the systolic blood pressure decreased from 170 to 110 mm Hg 30 minutes after the institution of the peribulbar block.
We did not observe any retinal ischaemia or ischaemic optic neuropathy.
| Surgical conditions|| |
The peribulbar block, with or without sub-Tenon infiltration, proved satisfactory in 95% of the patients, who would choose the same anaesthetic method for a similar surgery.
The only complaint was a backache because of the long decubitus, despite the comfortable position with a pillow under the flexed legs. Surgical conditions were judged to be optimal by the surgeon in 99% of cases.
| Discussion|| |
Peribulbar anaesthesia has increased in popularity because it provides the same anaesthetic effect as a retrobulbar injection, but with a lower rate of complications. For posterior segment surgery it appears to be necessary to choose an anesthetic mixture and a sufficient volume for the most potent and prolonged effect.
It is not possible to statistically compare this study with our earlier one because the sample size was different; the patients were not randomized, and the two studies were not double masked. However, some of the results offer an interesting comparison, leading us to believe that the new mixture is safe and effective.
In our former study a combination of etidocaine, bupivacaine and hyaluronidase was used. We had chosen to make a mixture with hyaluronidase because it was routinely added to local anaesthetics to accelerate the onset of anaesthesia. The hyaluronidase is extracted from ovine testis. We have used medical products of bovine origin for a long time, but in the past 10 years there has been evidence that these products could be associated with Creutzfeldt-Jacob disease. Similar public health concerns could extend to medical products of ovine origin even though no reports have been published yet. Hence, we decided to work on a new anaesthetic mixture and designed this study to determine whether we could easily obtain a similar satisfactory anaesthesia without hyaluronidase.
Clonidine is a centrally acting antihypertensive drug. It selectively stimulates alpha-2 inhibitory neurons in the medullary vasoconstrictor center and results in a decrease in sympathetic nervous system outflow from the central nervous system to peripheral tissues. It is clinically used first to stabilize perioperative haemodynamic response to stimuli (surgical skin incision, tracheal intubation, etc) by inhibiting cathecolamine release centrally and peripherally, and secondly to decrease the anaesthetic requirement for inhaled anaesthetic, sedative hypnotics and opioids. Homeostatic cardiovascular reflex are maintained, thus avoiding the problem of orthostatic hypotension. The most frequent side effects are sedation, anxiolysis, xerostomia and bradycardia. Clonidine is also known to decrease intraocular pressure.
With analgesia and akinesia the percentage of success was almost similar with the two mixtures. In both studies, the sub-Tenon infiltration was required with the same percentage (15%) and failed to produce analgesia in 1% of cases. Thus the previously tested mixture of etidocaine, bupivacaine and hyaluronidase is as efficient as the newly tested mixture of lidocaine, bupivacaine and clonidine. Using a similar technique we injected lower volumes (14.5 ± 3.5 ml) of the new mixture than previously used (17 ± 4.5 ml). We did not encounter any neurologic or cardiac complication as opposed to our previous study in which generalised epilepsy was seen in 2 patients and severe reduction of blood pressure in 4 patients. Moreover, in one patient the convulsions appeared 15 minutes after the injection, perhaps because hyaluronidase probably facilitates plasma intake of the anesthetic drugs from the peribulbar space. However, a fault in the technique of anesthetic administration cannot be categorically denied.
We did not observe any retinal ischaemia or ischaemic optic neuropathy. Though this series of 100 procedures is small compared to the incidence of 0.006 - 0.04% reported in the literature in peribulbar anaesthesia, we tend to believe that the mixture made of lidocaine, bupivacaine and clonidine is safer than the mixture with hyaluronidase.
Some authors have reported that the use of clonidine as a component of the peribulbar block in patients undergoing cataract surgery did not produce differences between groups with respect to pain, sedation, or satisfaction scores. Currently phacoemulsification is even performed under topical anaesthesia. Some topical anaesthetics are sufficient to control analgesia during the procedure. Cataract surgery is recognized as a very low pain procedure. Retinal reattachment surgery is considered a painful procedure and hence the efficacy of clonidine is better assessed in this condition. The cardiac complications described by Mjahed K et al with clonidine used at a dose of 2 mg/kg in retrobulbar block were not seen in our study, possibly due to a lower dose of clonidine (1 mg/kg). We chose to add clonidine in our mixture, because clonidine as a component of peripheral,, or retrobulbar block, is known to increase the efficacy and duration of the blocks. Unmasked study design and lack of controls are the inherent weaknesses of this study. Until a larger, well-designed study is conducted, the effect of clonidine will continue to be debated.
However, our results suggest that peribulbar anesthesia, using the combination of 2% lidocaine, 0.5% bupivacaine and 1 mg/kg clonidine, provides excellent surgical conditions and analgesia in 85% of the patients. This can be increased to a 99% satisfaction score if it is supplemented with a sub-Tenon infiltration, performed by the surgeon immediately before the surgical procedure. However, further randomized double masked studies are required to confirm the efficacy of this mixture.
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[Table - 1]