|Year : 1956 | Volume
| Issue : 1 | Page : 1-6
Sedation with analgesia in ocular surgery
Sir Cawasji Jehangir Eye Hospital, Bombay, India
|Date of Web Publication||10-May-2008|
H D Dastoor
Sir Cawasji Jehangir Eye Hospital, Bombay
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Dastoor H D. Sedation with analgesia in ocular surgery. Indian J Ophthalmol 1956;4:1-6
In modern surgery, whether general or specialized, perfect anaesthesia with pre and post operative sedation are of paramount importance. In this paper, I propose to present the results obtained with Pethidine-Chlorpromazine combination used in 350 cases of various operations performed at the Sir Cowasji Jehangir Eye Hospital.
The initial experience with this combination in pre and post operative sedation in different types of operations in eye surgery were so satisfactory that I was prompted to conduct a systematic investigation on not only the therapeutically desirable effects of the drug but also the undesirable side effects of the drug with a view to eliminate them on a large series of cases.
Before the advent of chlorpromazine the drugs used were bromides, halogenated hydrocarbons like chloral hydras, barbiturates opiates, and pethidine. All these, except pethidine and opiates, suffered from the disadvantage of having very little analgesic effect so that they proved extremely ineffective in presence of pain. While opiates and pethidine though they are powerful analgesic agents are disadvantageous in producing nausea and vomiting in fairly large percentage of cases, and besides, opiates also produce suppression of micturition and also constipation. Hence the need for some more effective analgesic and sedative drug or combination of drugs with minimal side effects was wanting. I think, as the present paper demonstrates, the new drug Chlorpromizine combined with Pethidine is an answer to this problem. I do not want to deal with the pharmacology of these drugs namely chlorpromazine hydrochloride and pethidine but a few facts which are both interesting and instructive are worth mentioning.
Chlorpromazine is a new phenothiazine derivative belonging to the antihistaminic group. It is a crystalline white powder very soluble in water. Antihistaminic compounds as a group, besides being depressants have the property of being antihistaminic, antiadrenergic, anticholinergic and locally anaessthetic. By suitably modifying the chemical structure of this group of compounds it is possible to accentuate some of the pharmacological actions and depress the others. By such modification chlorpromazine was obtained. In this drug, the neurodepressant action and antiadrenergic action have been accentuated white anticholinergic and antihistaminic actions have been largely eliminated. Experimentally and clinically, it is estimated that chlorpromazine is an antiemetic. antipruritic, hypothermic and calms down rapidly the psychomotor activity without producing general depression. In addition it enhances and prolongs the effects of analgesics. hypnotics and narcotics and enables them to be used with minimal side effects. In general medicine this drug has been tried for controlling hiccough, nausea and vomiting even of intractable origin, in several conditions besides that occurring in pregnancy. It is also used in hyperpyrexias and neuralgias. This drug has been used extensively in psychiatric practice to control the excitement psychosis, neurosis, schizophrenia and has the unique property of completely eliminating fear and apprehension thereby achieving confidence in the mind of the patient which is of great advantage in preparing the patient to undergo any major or minor, surgery. This unique property of the drug besides its other abovementioned properties prompted me to utilize this drug in ophthalmic surgery. As regards dosage this drug may be given orally and parentarally. The recommended normal dose, initially for an adult may be 75 mgm. orally during first 24 hours i.e. I x 25 mgm tablets T.D.S. and this dose should be modified according to the age and tolerance of the drug. In cases where nausea and vomiting are already present it is beneficial to commence the treatment with parenteral administration changing to oral route as soon as the condition is controlled. Among the side effects with prolonged and extensive use of the drug, damage to liver tissue resulting in jaundice has been reported, but in operative work its prolonged use is not required and hence this draw-back has never been observed. The important and immediate side-effect is fall in bloodpressure which has always been avoided by controlling its dose depending upon the general constitution of the patient as will be described later. This drug is contra-indicated in patients with cardiac and liver diseases and in hypotensives. It is essential that the patient must be kept in recumbent position when under the effect of this drug in order to avoid postural giddiness, though with the help of an attendant he can walk for a short distance to the operation table.
Pethidine hydrochloride is a synthetic piperidine derivative discovered in 1939 by Eisleb and Schaumann. It is given from 50 mgm. to 200 mgm.; the average dose is of 100 mgm. most frequently used and could be repeated 8 hourly. Pethidine relieves pain with lesser intensity than morphine but it has the advantage that it relaxes the spasm of involuntary muscles and is less depressant to the respiratory centre. Over-dosage may cause vasodilatation and giddiness. It is used as a substitute for morphine in pre-and post-operative pain and as a premedication in general anaesthesia. It has no significant untoward effect on the cardio vascular system as such, though it may to some extent lower the bloodpressure due to its vaso- dilatory action. The main draw-back of this drug is in producing nausea and vomiting. The satisfactory effect of a combined administration prompted me to administer these two drugs simultaneously by intramuscular injection one hour before the operation thereby giving a very prompt and controlled effect. Given intra-musculary the dose of pethidine has been kept constant to 100 mgm. It is combined with chlorpromazine from 15 to 20 mgm, upto a maximum of 25 mgm, intramuscularly.
Having reviewed the individual pharmacological and therapeutical actions of these two drugs I attempted to utilize their synergic actions by suitably adjusting their dosages in combination. The combined, effect of these two drugs not only intensified and prolonged the analgesic effect of pethedine but also gave the unique advantage of Chlorpromazine, in removing from the mind of the patient all the apprehension and fear of an operation. Beside this, chlorpromazine supressed nauesa and vomiting which could have been caused by pethidine alone.
In the earlier series of a group of cases, 50 mgm. of chloropromizine alone was administered orally which did not show any analgesic, effect apart from the removal of 'fear factor'-control of nausea and fall in the blood-pressure. In a similar group of cases 100 mgm. of pethedine alone was tried intramuscularly producing some general analgesia without eliminating nervousness and apprehension and also producing nausea and vomiting in many cases. Since a large dose of chlorpromazine produces a fall in blood-pressure it should be administered as per above mentioned dosage with 15 mgm, for a thinly built old patient especially and plethoric patients especially with high blood-pressure. These two drugs can be combined in the same syringe and injected intra-muscularly one hour before the operation and the patient is kept in a recumbent position. If an overdose of chlorpromazine causes a great fall of B.P., there need not be any cause for alarm as the same can be readily corrected by immediate parenteral administration of nor-adrenalin, and similar drugs like Methedrine which raise the blood-pressure by producing peripheral vase-constriction. Hence the usual average dose intramuscularly of 100 mgm. pethedine combined with 18 mgm. of chlorpromazine gives the meet satisfactory results by effecting perfect sedation and generalised analgesia. Excepting for some sedative on the night before no other form of sedation should be administered before the operation.
These drugs have also been tried with proper dilution intra-venously in a few cases without any added advantage. Apart from a very quick and deep effect there is also the danger of sudden fall in blood pressure. It also necessitates the use of an intra-tracheal tube. This technique of intro-venous administration requires the presence of an anaesthetist. Due to all these draw-backs 1 do not recommend its use intra-venously. The intra-muscular administration gives the most satisfactory results.
The patient remains in relaxed condition often going into a deep slumber during and after the operation from which he can be aroused. The painful reflexes like pinching of skin, etc..., are abolished, cough reflex and sneezing is suppressed effectively by the antihistaminic action of the drug. There is no vomiting or retention of urine. The usual duration of the effect is from 3 to 6 hours and if required the same dose could be repeated 6 to 8 hourly. Such a condition during an operation is of a great advantage for a nervous, unruly and a highly strung patient as well as -in painful diseases thereby eliminating in many cases the necessity of administering general anaesthesia. This mode of sedation and analgesia has been found of great advantage in painful eye-conditions like that of acute glaucoma. enucleation and evisceration, etc. It is also of advantage in patients with cough and with hypertension where with slightly higher dose of chlorpromazine, the blood-pressure can be brought down to a safer level. In extraocular operations, after resting for about an hour or two, patients can return home without any untoward symptom. It is hardly necessary to mention that the usual anaesthesia with surface instillation, infiltration, retro-bulbar ciliary and facial nerve blocks wherever necessary in different eye operations are essential requisites as per routine practice.
I briefly summarize the data collected of 350 cases of the Sir Cawasji Jehangir Ophthalmic Hospital, Bombay. Out of 350 cases, 288 were cataract extractions including complicated cataracts and 62 being miscellaneous operations as-12 Glaucoma, (10 Iridenclisis, 1 trephining, I cyclo-diathermy), 5 iredectomies, 2 iridotomies, 3 paracentesis, 4 needlings, 2 keratoplasties, 2 retinal detachments, 2 removal of intraocular foreign bodies, 2 muscle surgery in squint, 16 dacryocystectomies, 5 dacryocystorhinostomies and polythene intubations. 3 enucleations. 2 eviscerations, I entropion and 2 lid surgery and repair.
The intra-muscular dosage was adjusted according to the age and general constitution of the patient as described previously. The changes in the blood pressure before and after the administration as well as the effect on the intraocular tension were observed. I came across only 3 cases where the patient's blood pressure fell to a considerable level but that was due to the mistake in two cases in not making the patient recumbent after injecting the drug and in one case the dose given was rather high. I did not come across any case of nausea and vomiting. Slight dryness of mouth and tachycardia were quite common. Several cases with chronic cough showed satisfactory suppression of the cough reflex. On an average, following the usual dose of intra-muscular administration in patients with normal blood pressure there was a reduction of 10 to 20 mm. of Hg. in systolic and 5 to 10 mm. of-,HR. in diastolic pressures. However this reduction in blood pressure was of greater extent in hypertensive cases with a slightly larger dose of chlorpromazine. As regards the intra-ocular tension there was no appreciable effect excepting for a slight reduction of about 3 mm. of Hg.. presumably due to general relaxed condition of the patient and of the muscles of the eye-ball. This combination was also repeated as a post-operative sedation in a number of cases with most satisfactory results.
In conclusion I must add that during the operation, to the patient the feeling is of getting an operation done as if under general anaesthesia, and to the surgeon it gives the feeling of doing surgery on a quiet and relaxed condition of the patient as if under intravenous pentothal anaesthesia with the added advantage of having the patients' co-operation whenever required. I am confident that the complete satisfaction obtained in producing effective analgesia and sedation with perfect safety in Opthalmic Surgery will prove equally useful in other branches of surgery as well.
The drug "Chlorpromazine Hydrochloride" used was supplied by Messrs. May and Baker (India) Ltd., under their trade name "LARGACTIL 50 mgm. in 2 cc. ampoules. The Pethedine was supplied as "UNI-PETHIDINE" by the Unichem Laboratories. Bombay. To these two firms I am thankful for their co-operation in supplying our requirements.
I extend my thanks to my Resident House Surgeon Dr. S. D. Athavale. for carrying out these investigations under my instructions.
Lastly, I thank Dr. D. P. Sethna, F.R.C.S.E.. Superintendent. Sir J. J. Group of Hospitals, Bombay, for the facilities offered, to carry out the investigations.
| Discussion|| |
Dr. S. G. Shippard (London): Being an anaesthetist myself I have had occasion to use largactil many times in ocular surgery, general as well as local. I endorse the merits chlorpromazine in controlling vomiting, producing sedation and boosting the action of an analgesic. However, pethedine is the more dangerous of the two drugs and may cause vomiting in spite of its combination with chlorpromazin. I suggest a smaller dose (10mg) at intervals given intravernously before the operation. It combines well with chlorpromazin but it must be given by an anaesthetist.
In the post-operative stage, chlorpromazin 25 mgm. given at 6 hourly intervals has an analgesic as well as sedative effect. There is no need to give pethedine in post-operative stages unless there is gross pain.
Dr. Dastoor: Intravenous administration necessitates the services of a fulltime anaesthetist attached to the eye-department, a luxury which is not possible at the present stage of hospital practice in India. We have to do without an anaesthetist most of the time and so an intramuscular route is preferable for safety conditions in India.
Dr. S. N. Kaul (Delhi): Pethedinc by itself gives rise to troublesome nausea, sometimes for 2 days which is disgreeable to the patient and the surgeon. Does chlorpromazin reduce this side-effect of pethedine
Dr. Dastoor. This is exactly what chlorpromazin does, no vomiting or nausea due to pethedine after the operation.
Dr. Preen Chamdra. (Patiala) : I have met with two complications of chlorpromazin not mentioned by others. (I) excessive yawning in one patient making it difficult to operate. (2) a patient when asked to look down tried to sit up, a kind of a false response to an order.
Dr. Dastoor : Having used this combination now in approximately a thousand cases, I have not cone across such a complication even once.
Dr. J. M. Pahwa (Sitapur) confirmed) the sedative and antiemetic effects of largactil given orally from two days before the operation (25 mgm x 3 first day, 25 mgm. x 2 the second day and 25 mgm. half an hour before operation.