Abstract
The intraprocedural immobilization of selected subsets of patients undergoing pars plana vitrectomy (PPV) requires the performance of general anesthesia (GA), which entails the intraoperative use of hypnotics and titration of opioids. The Adequacy of Anesthesia (AoA) concept of GA guidance optimizes the intraoperative dosage of hypnotics and opioids. Pre-emptive analgesia (PA) is added to GA to minimize intraoperative opioid (IO) usage. The current additional analysis evaluated the advantages of PA using either COX-3 inhibitors or regional techniques when added to AoA-guided GA on the rate of presence of postoperative nausea and vomiting (PONV), oculo-emetic (OER), and oculo-cardiac reflex (OCR) in patients undergoing PPV. A total of 176 patients undergoing PPV were randomly allocated into 5 groups: (1) Group GA, including patients who received general anesthesia alone; (2) Group T, including patients who received preventive topical analgesia by triple instillation of 2% proparacaine 15 min before induction of GA; (3) Group PBB, including patients who received PBB; (4) Group M, including patients who received PA using a single dose of 1 g of metamizole; (5) Group P, including patients who received PA using a single dose of 1 g of acetaminophen. The incidence rates of PONV, OCR, and OER were studied as a secondary outcome. Despite the group allocation, intraoperative AoA-guided GA resulted in an overall incidence of PONV in 9%, OCR in 12%, and OER in none of the patients. No statistically significant differences were found between groups regarding the incidence of OCR. PA using COX-3 inhibitors, as compared to that of the T group, resulted in less overall PONV (p < 0.05). Conclusions: PA using regional techniques in patients undergoing PPV proved to have no advantage when AoA-guided GA was utilised. We recommend using intraoperative AoA-guided GA to reduce the presence of OCR, and the addition of PA using COX-3 inhibitors to reduce the rate of PONV.
Highlights
The 3% postoperative nausea and vomiting (PONV) incidence rate among patients receiving COX-3 inhibitors was quite an achievement when compared to that of the abovementioned literature, even in those underlining the superiority of peribulbar blocks (PBB) with monitored anesthesia care regarding the reduction in PONV incidence rate after pars plana vitrectomy (PPV)
In patients undergoing PPV, we recommend Adequacy of Anesthesia (AoA) guidance of general anesthesia (GA) to ensure the equal depth of anesthesia through the administration of inhalational hypnotics, as reflected in the SE value, and proper dosage of intraoperative opioid (IO), as reflected in the surgical pleth index (SPI) value
We recommend no addition of regional techniques such as topical anesthesia and PBB using bupivacaine and lidocaine mixture because their use may lead to unwelcome complications, take more time, and impair economic frugality
Summary
The utility of response and state entropy (RE and SE) in ensuring the proper depth of hypnosis, as volatile anesthetic agents tend to blunt the hemodynamic response to nociceptive stimulation [6] and surgical pleth index (SPI) to determine the proper nociception/antinociception balance [7,8], reduced the cumulative dose of intraoperative opioids (IO) during GA [9], reduced the use of hypnotics, and shortened emergence and length of stay times in the postanesthesia care unit (PACU) [10] They decreased the rate of postoperative intolerable pain perception (PIPP) [11]. Various methods of preventive analgesia (PA) for PPV, such as regional techniques [12,13,14,15,16,17,18,19,20], and intravenous techniques with preoperative infusion of COX-3 inhibitors (paracetamol, metamizole) [21,22], were shown to provide adequate postoperative analgesia [17], with a fall in the rate of main adverse events [12,15,23] within the mechanism of a reduction in demand for IO.
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