Beruflich Dokumente
Kultur Dokumente
s u m m a r y
Keywords:
Vitreo-retinal surgery
Local anaesthesia
General anaesthesia
Many patients presenting for V-R surgery are elderly with a high incidence of associated medical
conditions. Thorough preoperative assessment is essential especially for those scheduled for general
anaesthesia.
Patients on anticoagulants and antiplatelet drugs scheduled for V-R surgery should continue their
routine medication. However, where there are specic concerns, the anaesthetist, surgeon and patient
should discuss the risks and benets of continuing their routine medication to agree an acceptable
approach.
Local anaesthetic techniques are now far more commonly used than general anaesthesia for V-R
surgery. Clinicians must recognize the limitations and contraindications of both approaches.
Whenever local anaesthetic techniques are used, attention to small details can make a huge difference
to patient comfort. This often entails meticulous patient positioning and clear lines of communication
between patient and the theatre team. Sometimes, sedative drugs are benecial to patient care.
Careful patient monitoring is recommended during V-R surgery because of the darkened theatre
environment, the age and associated medical conditions of many of these patients, and the risk of
precipitating abnormal cardiac rhythms from drugs and the oculocardiac reex.
2010 Elsevier Ltd. All rights reserved.
1. Introduction
2.2. Vitrectomy
This operation has been used for more than 50 years for the
treatment of retinal detachment and may be undertaken under
local (LA) or general anaesthesia (GA).
The operation involves observing with the indirect ophthalmoscope to locate retinal holes and treating them externally with
cryotherapy. To enable easy movement of the globe, traction
sutures are placed round the recti muscles. Pulling on these during
* Corresponding author. Tel.: 44 121 507 4343; fax: 44 121 507 4349.
E-mail address: k-l.kong@swbh.nhs.uk (K.L. Kong).
0953-7112/$ e see front matter 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.cacc.2009.11.008
K.L. Kong, G. Kirkby / Current Anaesthesia & Critical Care 21 (2010) 174e179
175
Table 1
Contraindications to local anaesthesia.
Absolute Patient refusal
True allergy to local anaesthetic
Orbital infection
Inability of patient to cooperate with theatre staff (dementia, children
and those with learning disabilities)
Inability to lie still (tremors, epilepsy, dystonic movements)
Relative Inability to lie at (cardiac or respiratory disease)
Intractable cough
Patients with communication difculties (profound deafness,
language difculties)
Prolonged surgery (greater than 2 h)
Claustrophobia
Previous surgery in the same eye (scleral buckling, excision of orbital
tumours)
Deep set eyes
Nystagmus
Operations on the only one sighted or partially sighted eye
Young patients
3.2. Investigations
As far as ophthalmic patients are concerned, no routine
screening tests have been shown to be helpful or to improve the
outcome. A large multicentre trial4 showed that routine preoperative blood tests and electrocardiogram in cataract patients did not
increase the safety of surgery. The Joint Colleges' Guidelines (2001)5
for local anaesthesia recommend that tests should only be
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Table 2
Reasons for increased local anaesthesia rate for vitreo-retinal surgery.
Safer and effective LA techniques (peribulbar and sub-Tenon's anaesthesia)
Reduction in in-patient hospital beds
Patients more accepting of LA to avoid the disadvantages of GA
Efforts of anaesthetists in promoting LA
Table 3
Advantages of local anaesthesia for vitreo-retinal surgery.
Patient benets
Resource benets
K.L. Kong, G. Kirkby / Current Anaesthesia & Critical Care 21 (2010) 174e179
5. Intraoperative considerations
5.1. Optimal operating conditions
Surgical requirements for V-R surgery include a well anaesthetized eye that is still in the neutral gaze position. For patients
receiving a general anaesthetic, this requires the administration of
muscle relaxants and mechanical ventilation which also facilitates
the control of end-tidal carbon dioxide concentrations. When
muscle relaxants are used, neuromuscular transmission should be
monitored to avoid any sudden wearing off of relaxant and patient
movement. A continuous infusion of an appropriate muscle
relaxant such as atracurium has its merits in avoiding the peak and
trough concentration effects. A remifentanil infusion in place of
nitrous oxide during V-R surgery is gaining popularity. However, it
is inadvisable to rely on a remifentanil infusion to provide immobility as sudden patient movement has occurred during surgery and
resulted in surgical instruments damaging the patient's eye.
5.2. Laryngeal Mask Airway (LMA) versus endotracheal tube (ETT)
Airway access is limited during V-R surgery under general
anaesthesia, therefore it is essential to secure the airway prior to
commencement of surgery, either with a LMA or an ETT. In the
absence of specic contraindications, the armoured/exible LMA is
increasingly favoured by ophthalmic anaesthetists as the airway
device of choice. It has the advantage of minimal change in systemic
arterial and intraocular pressure during insertion and removal, and
a lower incidence of sore throat compared to endotracheal intubation.
5.3. Monitoring
Vitrectomy operations, cryotherapy, laser therapy and indirect
ophthalmoscopy take place in a darkened room. The anaesthetists'
vision may be further obscured by protective goggles during laser
treatment. Anaesthetists must have access to some form of
controlled lighting to ensure safety in patient monitoring, record
keeping, and the routine checking of equipment and drugs. Under
these adverse conditions where patient access may also be limited,
full patient monitoring with appropriate alarms is essential.
5.4. Nitrous oxide (N2O) and intraocular pressure
During vitreo-retinal surgery, intraocular gases are often used to
tamponade retina holes so that the neuroretina is in apposition
against the pigment epithelium and retinopexy can take effect. If
there is a gas bubble in the eye and the patient is under nitrous
oxide anaesthesia, then N2O can enter the gas bubble, causing it to
expand leading to a rise in intraocular pressure in the closed eye. If
this rises above the perfusion pressure of the central retinal artery
(about 70 mm Hg), then occlusion may occur, carrying the risk of
permanent blindness.
Traditional recommendations are either to avoid the use of N2O
completely or to withdraw the agent 15 min or more before the
injection of intraocular gas. However, the clinical benets of such
anaesthetic approaches have never been demonstrated for
primary vitreous surgery. Briggs and colleagues (1997)11 found
177
that anaesthesia using nitrous oxide does not adversely affect the
size of a C3F8 gas bubble as the gas kinetics would only apply to
the closed eye situation. During vitrectomies, uncontrolled leakage
from sclerostomy sites is the predominant factor in determining
bubble size. Moreover, the diffusion of N2O into intraocular gas
bubbles is time dependent and if intraocular gas is introduced just
before the cessation of surgery and anaesthesia, then the effects of
N2O would be negligible.
The risk does arise however, in the situation where the surgeon
has nished operating on one eye, closes it and then proceeds to do
some procedure on the other eye. In this situation, N2O must be
discontinued as soon as the rst eye has been closed.
A major danger arises if patients with intraocular gas are
subsequently subjected to general anaesthesia using N2O.12 Several
case reports have described severe visual loss in those patients
undergoing nitrous oxide anaesthesia in the presence of an intraocular gas bubble. Intraocular gas duration varies. Generally, larger
and more concentrated volumes of gases that are less soluble last
longer. Air is typically absorbed within a few days; SF6 lasts
approximately 10 days and C3F8 about 6 weeks although durations
in excess of 70 days have been reported.
In an aircraft, during decompression, intraocular gas expands
and can produce the same deleterious effects.
Patients who have had intraocular gas injections should be
advised of these risks and provided with a notication wristband
(Fig. 1) warning against both ying and the use of nitrous oxide
until the gas has been completely absorbed.
5.5. The oculocardiac reex
The oculocardiac reex is a trigemino-vagal reex rst
described in 1908. It can result in dangerous atrial and ventricular
arrhythmias including severe bradycardia or cardiac standstill. The
incidence of the reex is high in certain V-R procedures such as
cryo-buckling surgery where traction of the extraocular muscles
may precipitate this reex. Hypoxaemia, hypercarbia or light levels
of general anaesthesia are known to exacerbate the bradycardic
response of this reex. A remifentanil infusion would also make the
bradycardic response worse.
The afferent limb of the reex is via the long and short ciliary
nerves (ophthalmic division of the trigeminal nerve) relaying via
the ciliary ganglion, terminating in the trigeminal sensory nucleus
in the oor of the fourth ventricle. The efferent limb passes down
the vagus nerve to the heart.
Local anaethetic eye blocks attenuate the afferent limb of this
reex and may be preferable to general anaesthesia for adult
surgery in which traction of the extraocular muscles is a signicant
problem. The efferent limb is blocked by antimuscarinics such as
glycopyrrolate.
However, as no one anaesthetic technique reliably abolishes the
oculocardiac reex, patients undergoing V-R surgery must be
carefully monitored.
5.6. Mydricaine
It is vital that the pupil stays dilated during a V-R operation so
that the surgeon has an excellent view of the posterior segment.
Fig. 1. Picture of wristband warning against ying and repeat nitrous oxide anaesthesia in patients with intraocular gas.
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K.L. Kong, G. Kirkby / Current Anaesthesia & Critical Care 21 (2010) 174e179
179
Conict of interest
None.
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