|Year : 1983 | Volume
| Issue : 1 | Page : 11-14
Anaesthetic problems in retinal detachment surgery (An evaluation of 270 anaesthetics)
HH Dash, MK Arora, HL Kaul, N Saxena, Sunil Kumar
Deptt. of Anaesthesiology, A.U. M.S., New Delhi, India
H H Dash
Deptt. of Anaesthesiology, A.I.I.M.S., New Delhi-110 029
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Dash H H, Arora M K, Kaul H L, Saxena N, Kumar S. Anaesthetic problems in retinal detachment surgery (An evaluation of 270 anaesthetics). Indian J Ophthalmol 1983;31:11-4
Retinal detachment surgery presents a multitude of problems to the anaesthesiologists. Majority of the patients are elderly with systemic disorders and psychological disturbances. Duration of operation is long and reoperations not infrequent. The surgical procedure often entails traction of the extraocular muscles which may give rise to cardiac arrhythmias due to stimulation of the oculocardiac reflex. Encircling procedure may increase intraocular tension. Anaesthetic problems observed during 270 retinal detachment operations at the Dr. R.P. Centre for Ophthalmic Sciences, New Delhi are presented here.
| Materials and methods|| |
Majority of patients were males (220) and in the age group of 41-60 years. The youngest being 7 years and oldest 80 years of age [Table - 1]. Forty five patients had reoperation in same or other eye. Pre-operative assessment revealed associated medical diseases, in a number of patients [Table - 2].
Hypertension and diabetes were controlled with appropriate medical therapy. Antihypertensive and beta-blockers were continued till the day of surgery. Patients on oral antidiabetic drugs were not changed to crystalline insulin, and patients with obstructive airway diseases were given bronchodilators, antibiotics and physiotherapy. Night sedation in the form of diazepam was prescribed whenever required.
Majority of patients received pethidine (1mg/kg), promethazine (0.5mg/kg) and atropine (0.01 mg/kg) intramuscularly as premedication 45-60 min. before surgery. Diazepam (0.25mg/kg) and atropine was administered in 20 patients, while 12 patients received prochlorperazine (12.5mg.) in conjunction with pethidine and atropine.
Anaesthesia was induced with intravenous 2.5% thiopetone (4-5mg/kg) in 252 patients and ketamine (2mg/kg) in three patients with bronchial as thama. Halothane and 0 2 was employed mostly in children and patients of chronic obstructive airway disease. Suxamethonium (1.5mg/kg) was used to facilitate intubation. Anaesthesia was maintained with N 2 0 and 0 2 (3:2), nondeplolarising muscle relaxants, pethidine and IPPV in 214 patients. N 2 0 & 02 was supplemented with halothane in 56 patients breathing spontaneously. The residual effect of muscle relaxants was reversed with neostigmine (0.05mg/kg) and atropine (0.02mg/kg).
Pulse and blood pressure (sphygmomanometry) were recorded throughout the operative procedure and continuous ECG monitoring was carried out in patients with cardiac involvement, (116 patients).
Intra and Postoperative Problems
Intra operative problems encountered during anaesthesia are shown in [Table - 3]. Lignocaine (1mg/kg) bolus was required in five patients to revert ventricular ectopics to normal sinus rhythm. Excessive secretions, delayed recovery, laryngospasm and awareness were the minor post-operative complications, [Table - 4]. The commonest post operative complication (72%) was nausea and vomiting [Table - 5]. A significant reduction was achieved when prochlorperazine was used in place of promethazine for premedication. One interesting observation made during this study was that vomiting occurred in majority of patients only after they were shifted to the ward 2-3 floors below the operating room. This was despite the fact that all patients were fully awake at the time of transfer and had not complained of nausea or vomiting prior to transfer. Blood pressure recorded before and after transfer was found to be normal.
Two patients had intra-operative myocardial infarction. One patient developed acute pulmonary oedema 24 hours after anaesthesia which responded to IPPV with 100% 0 2 , morphine and diuretics. However, this patient died on the 6th post-operative day following a second episode. Second patient made an uneventful recovery. The patients with chronic lung diseases who required overnight IPPV with Bird Ventilator for repiratory insufficiency recovered uneventfully.
| Discussion|| |
Preoperative assessment is mandatory in patients with retinal detachment because of high incidence of associated medical problems. It also helps to build rapport with the very anxious and emotionally disturbed patient. The eye can easily by rendered immobile and insensitive to pain by local anaesthesia. But, the higher incidence of side-effects, unpredictable analgesia and short duration of action are its major limitations. Improvement in general anaesthetic techniques resulting from a wider choice of drugs and improved safety have made general anaesthesia as the method of choice for such operations.
Higher incidence of pre-operative hypertension and coronary artery disease (CAD) in our series is probably due to its high incidence in the older age group. We recommend preoperative control of hypertension in order to prevent complications in the cardio-vascular haemodynamics during operative and post operative period. Recent myocardial infraction (within 6 months) is a contraindication for anaesthesia as there is 33% risk of reinfraction in the post operative period. Recent reports have claimed the superiority of local analgesic technique over general anaesthesia in such conditions. High incidence of cardiac arrhythmias may be of reflex origin and occur mainly due either to traction of the extraoccular muscles or passing scleral sutures.
Continuous E.C.G. display is undoubtedly of great help.
It is also recommended that patients with lung diseases be well controlled pre-operatively, with antibiotics, bronchodilators and physiotherapy. But despite that patients with chronic pulmonary dysfunction may have significant post-operative respiratory issufficiency and hypoxaemia, which may requirf ventilatory support.
The incidence of post operative sickness is relatively high following ophthalmic surgery and it was found in more than (70%) of our patients receiving routine premedication (i.e pethidine, promethazine and atropine) Addition of prochloroperazine, a poten antiemetic, reduced the incidence significantly attempted in any of our patients. Droperidol a butyrophenone derivative is an effective long
acting antiemetic and if used in premedication may further reduce the incidence of sickness.
| Summary|| |
The pre-intra and post-operative problems encountered during 270 anaesthetics for retinal detachment surgery are highlighted. Hypertension, CAD and diabetes mellitus were the most common preoperative problems, while cardiac arrhythmias was the most common intra-operative problem encountered.
| References|| |
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[Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5]