sub-Tenon's Infiltration Research Articles

Comparison of peribulbar block and subtenon infiltration in pediatric enucleation for retinoblastoma

Purpose:Enucleation performed in children with retinoblastoma is associated with severe postoperative pain. The use of opioids for the pain is associated with numerous complications which demand careful monitoring. Subtenon infiltration and peribulbar block are useful in ameliorating pain perioperatively following various ophthalmic surgeries which are yet to be evaluated in enucleation. Therefore, we designed this study to compare the effects of peribulbar block and subtenon infiltration on postoperative pain with opioids in pediatric enucleation surgeries.Methods:60 children of American Society of Anesthesiologists grade I and II, age ranging from 6 months to 6 years with retinoblastoma undergoing enucleation surgery were included in the study. Group A (n = 20): received peribulbar block (peribulbar group); Group B (n = 20): received subtenon local infiltration (subtenon group); and Group C (n = 20): no block was given.Results:The postoperative fentanyl consumption was lowest with Group B compared to Group A and Group C (P value 0.001). However, the total fentanyl consumption was comparable between groups A and B, while it was significantly higher in the control group. The mean pain score face, legs, activity, cry, consolability (FLACC) scale and mean time to discharge from post anesthesia care unit were lowest in Group B followed by Group A, while Group C had the highest. There was no statistically significant difference among the 3 groups with regards to side effects.Conclusion:Subtenon infiltration showed significantly better outcomes when compared to peribulbar block and intravenous opioids alone without any untoward adverse effects.

Adding low dose rocuronium to local anesthetic mixture: Effect on quality of peribulbar blockade for vitreoretinal surgery

BackgroundThe purpose of this study was to assess the effect of adding low dose rocuronium to local anesthetic solution on the quality of peribulbar blockade for vitreoretinal (VR) surgery.Methods80 consecutive adult patients scheduled for VR surgery were enrolled in this double-blind randomized clinical trial. Patients were categorized randomly into 2 equal groups: group C (control group) received local anesthetic mixture (4 ml lidocaine 2%, 4 ml bupivacaine 0.5%, and hyaluronidase “30 U/ml”) plus 0.5 ml normal saline, and group S (study group) received the same local anesthetic mixture plus 5 mg (0.5 ml) rocuronium. Globe and lid akinesia were assessed 15 min after injection, and supplemental peribulbar blockade was done in case of inadequate analgesia and or akinesia. Intraoperatively, supplementary sub-Tenon infiltration was performed in case of inadequate analgesia and/or akinesia. Measurement data included rate of supplementation, analgesic efficacy, time to first sub-Tenon infiltration, and total anesthetic volume. Major complications, and patient’s and surgeon’s satisfaction were also recorded.ResultsThe adequacy of peribulbar blockade 15 min after injection was comparable in both groups. Rate of supplementary sub-Tenon infiltration was lower in the rocuronium group which is statistically significant (15 injections versus 53 injections in the control group). Time to first sub-Tenon infiltration was significantly prolonged in the rocuronium group (90.4 + 11.8 versus 60.2 + 9.2 in the control group). The total anesthetic volume injected was significantly lower in the rocuronium group (13.2 + 0.6 versus 20.6 + 0.8 in the control group). There were no major systemic or local complications in both groups. Patient’s and surgeon’s satisfaction was significantly higher in the rocuronium group.ConclusionAdding low dose rocuronium to local anesthetics prolongs duration of peribulbar anesthesia and offers an optimal surgical condition without serious adverse effects for patients undergoing VR surgery.

Comparison of Topical Versus Sub-Tenon's Anesthesia in Phacoemulsification at a Tertiary Care Eye Hospital.

Purpose:To compare the effectiveness of topical and sub-Tenon's anesthesia in providing pain relief during phacoemulsification.Methods:This randomized controlled trial was carried out at a tertiary eye care hospital, Coimbatore, Tamil Nadu, India. Patients who underwent phacoemulsification through self-sealing clear corneal incision with foldable intra-ocular lens implantation were randomized into two groups. Group 1 (n = 100) received topical anesthesia with 0.5% proparacaine (Paracaine, Sunways India Pvt. Ltd., India) drops. Group 2 (n = 100) received sub-Tenon's infiltration with 2% lignocaine (Xylocaine, AstraZeneca Pharma India Pvt. Ltd., India). As per study criteria, patients graded the pain during administration of anesthesia, during surgery and after surgery on a visual analogue pain scale. The surgeon graded overall patient co-operation. The complications were also noted. Data analysis was performed using Statistical Package for Social Sciences version 11. Student's t-test and Chi-square test were used for comparison of variables between the groups.Results:Sub-Tenon's anesthesia provided statistically significant better intra-operative pain relief and patient satisfaction than topical anesthesiat. No statistically significant difference was noted between the two groups regarding pain during administration, postoperative pain, and surgeon satisfaction.Conclusion:Sub-Tenon's anesthesia provides better pain relief than topical anesthesia during phacoemulsification.

Patient-controlled sedation vs. anaesthetic nurse-controlled sedation for cataract surgery in elderly patients

Patient-controlled sedation (PCS) with propofol has been used successfully in various conditions, but controversies exist about its use in sedation of elderly patients for cataract surgery. This study evaluates the efficacy of anaesthetic nurse-controlled sedation (ACS) compared with PCS using the same device and the drug. All of the 153 elderly patients (aged 51-88 years) undergoing cataract surgery with a sub-Tenon's infiltration were assigned to receive ACS (n = 51) or PCS (n = 51) with propofol or no intra-operative sedation (control, n = 51). Propofol was administered with a bolus dose of 10 mg and a lockout interval of 1 min. Cognitive function, sedation, pain, anxiety, side effects and satisfaction of patients were evaluated. The mean +/- SD doses of propofol administered were 34.9 +/- 8.8 mg and 30.1 +/- 30.4 mg in the groups ACS and PCS, respectively. The anxiety score was lower in both ACS and PCS groups compared with control group but was not different between the two groups. Patient's satisfaction was highest in PCS group, ACS group was the next, compared with non-sedated group. Other parameters were not different among the three groups. Both ACS and PCS using propofol provided reduced anxiety compared with control, but patient's satisfaction was higher in the PCS group compared with ACS group.

Postoperative pain relief in vitreoretinal surgery with subtenon Bupivacaine 0.75%

Sir, The postoperative recovery period after vitreoretinal surgery can be quite painful and the degree of pain experienced is often related to the duration of the surgical procedure (Fekrat et al. 2001). Secondary analgesia has been noted to be necessary after subtenon ocular anaesthesia (Kwok et al. 1999). However, little has been written about subtenon infiltration analgesia given at the end of vitreoretinal surgical procedures. Subtenon infiltration of local anaesthetic is a relatively safe and easy procedure (Kwok et al. 1999). Hence we designed a prospective, randomized, double-blind pilot study to assess the efficacy of subtenon Bupivacaine 0.75% infiltration analgesia when used at the end of a surgical procedure to control postoperative pain. All patients undergoing vitreoretinal surgery under a standardized general anaesthetic, between January and April 2002, were selected. All the patients had pre-emptive analgesia with intramuscular Ketoprofen. They were told that they may or may not receive an injection of a pain-killing substance on completion of the surgical procedure and informed consent was obtained. Each patient was assigned to receive either 3 ml of Bupivacaine 0.75% or 3 ml of normal saline after completion of the vitreoretinal surgery, before the conjunctiva was sutured. The patients were randomized and were operated on by a single surgeon (KLG). A set protocol for postoperative oral analgesia in the recovery period was observed for all patients. This comprised oral Co-dydramol as a first line and oral Oromorph as a second line of medication. Patients' pain levels were recorded on a 3-point scale (mild, moderate and severe) by nursing staff at set intervals. These were at recovery, at 1 hour, at 3 hours and at 6 hours. Pain was classified as mild (requiring no analgesia), moderate (requiring oral Co-dydramol) or severe (requiring oral Oromorph). Fifteen patients (60%) received subtenon Bupivacaine and 10 (40%) received normal saline (controls). The surgeries included stand-alone external buckling procedures and vitrectomies with or without additional procedures. The duration of surgery varied from a minimum of 75 min to a maximum of 100 min, with a mean of 120 min. The types of surgeries and their duration were almost similar in the two groups. Four of the 15 patients (27%) receiving subtenon Bupivacaine 0.75% complained of some postoperative pain, which was mild to moderate in nature. Only two of these patients required additional analgesia. Nine of the 10 controls (90%) experienced postoperative pain and all of them needed analgesia. Most of them complained of pain within the first 3 hours after surgery. Five patients complained of severe pain and four of moderate pain. One patient had both nausea and vomiting. The efficacy of pre-emptive subtenon Bupivacaine 0.5% anaesthesia in retinal surgery was reported by Mahfouz & Nabawi (2002). However, to the best of our knowledge no other publication has documented the effect of subtenon Bupivacaine used after completion of retinal surgery, solely for the purpose of postoperative analgesia. In our series subtenon Bupivacaine 0.75% proved to be a safe and effective analgesic when used in patients undergoing vitreoretinal surgery under a general anaesthetic. Although the study groups were small, the results were statistically significant. However, a larger number of patients should be studied to validate the results of this research.

Correspondence

Correspondence

Sub-Tenon's infiltration using bupivacaine 0.5% decreases acute postoperative pain and opioid requirement after posterior segment surgery

Editor—Sub-Tenon's infiltration is recognized as a safe regional anaesthesia technique for phacoemulsification of the lens,1Zafirakis P Voudouri A Rowe S et al.Topical versus sub-Tenon′s anesthesia without sedation in cataract surgery.J Cataract Refract Surg. 2001; 27: 873-879Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar 2Tokuda Y Oshika T Amano S Inouye J Yoshitomi F Analgesic effects of sub-Tenon′s versus retrobulbar anesthesia in planned extracapsular cataract extraction.Graefes Arch Clin Exp Ophthalmol. 2000; 238: 228-231Crossref PubMed Scopus (3) Google Scholar and other ophthalmic procedures,3Calenda E Olle P Muraine M Brasseur G Peribulbar anesthesia and sub-Tenon injection for vitreoretinal surgery: 300 cases.Acta Ophthalmol Scand. 2000; 78: 196-199Crossref PubMed Scopus (31) Google Scholar but its analgesic effect has not been assessed in the postoperative period. After approval by the local ethics committee, and written informed consent had been obtained from the patients, we performed a prospective randomized double-blind study to compare the opioid requirement when bupivacaine was given by the sub-Tenon's route in posterior segment surgery. General anaesthesia was induced by propofol (1–2 mg kg−1), remifentanil and atracurium and was maintained with isoflurane and remifentanil (15–25 μg kg−1 min−1). Patients undergoing posterior segment surgery were chosen because the operation is more painful than phacoemulsification of the lens.4Calenda E Muraine M Evaluation of local anesthetic drugs in ophthalmic procedures.Reg Anesth Pain Med. 2001; 26: 491-492Crossref PubMed Scopus (3) Google Scholar One group (30 patients) received sub-Tenon's infiltration with bupivacaine 0.5%, 3 ml by the surgeon before the end of surgery, and in the control group (30 patients) only analgesic drugs were used. A visual analogue scale (10–100) was used to assess pain. We calculated the median values of the visual analogue scale for each group and used the Mann–Whitney U-test to compare groups. We studied the patients’ request for analgesic drugs throughout the operative period (up to 24 h from leaving the recovery room). We used Fischer's exact test to compare the groups. The mean (sd) age of the patients was 43 (14.1) yr (male 17, female 13) in the sub-Tenon's infiltration group, and 46 (14.7) yr (male 16, female 14) in the control group. The mean duration of surgery was 90 (30) min in the sub-Tenon's group and 88 (35) in the control group. No cardiac or neurological complications were seen. We did not observe any retinal ischaemia or ischaemic optic neuropathy. From the recovery room until 3 h after operation, the pain score was lower in the group with sub-Tenon's infiltration (P=0.000001). In the control group, all patients required analgesic drugs and some patients requested morphine as their pain score was 70. In the 3–6 h period, the pain score was significantly lower in the bupivacaine group (P=0.025). In the 6–24 h period, the difference was not significant. Consumption of analgesic drugs was considered for the 24 h from leaving the recovery room. Consumption of acetaminophen, ketoprofen and morphine was lower in the group receiving sub-Tenon's infiltration (P=0.0009). Sub-Tenon's infiltration with bupivacaine 0.5%, 3 ml offers excellent postoperative analgesia for up to 6 h and is more effective than other drugs. Furthermore, it is reliable and safe.

Sub-tenon infiltration to relieve postoperative pain in a child

Sub-tenon infiltration to relieve postoperative pain in a child

Peribulbar anesthesia and sub-Tenon injection for vitreoretinal surgery: 300 cases.

We carried out a prospective study in order to evaluate the efficacy and safety of peribulbar anaesthesia supplemented by a sub-Tenon injection in case of inadequate analgesia during vitreoretinal surgery. We performed 300 consecutive vitreoretinal procedures. Patients received a mean volume of 17+/-4.5 ml of a mixture of etidocaine 1%, bupivacaine 0.50% and hyaluronidase (25 UI/ml). Supplementation was represented by a sub-Tenon infiltration of lidocaine 2% (2 or 3 ml). This volume was not included in the mean volume. Analgesia was adequate throughout surgery without any supplementation in 85% of cases and with a sub-Tenon infiltration in 99%. Akinesia was complete in 82%, mild in 15% and absent in 3% of cases. The sub-Tenon injection was performed immediately before starting the procedure in 58% of cases and during the surgery with a delay of 80+/-21 min in 42%. Eleven patients (3.66%) were agitated during surgery and two of them needed a general anaesthesia to allow for the procedure. Generalised epilepsy was encountered in two patients (0.66%) immediately after the peribulbar injection in one patient and 15 min later in the other. The systolic blood pressure severely decreased between 60 to 70 mm Hg 40 min after the accomplishment of the peribulbar in 2 patients and at 90 min in 2 others. Our results demonstrate that peribulbar anaesthesia alone offers excellent analgesia in 85% of patients and supplemented by a sub-Tenon injection in 99%.

Sub-Tenon's infiltration of local anaesthetic with hyaluronidase

Sub-Tenon's infiltration of local anaesthetic with hyaluronidase

A new local anesthesia technique for cataract extraction by one quadrant sub-Tenon's infiltration.

A new technique of local anesthetic administration has been used for 50 patients undergoing cataract extraction. The simple technique involves direct transconjunctival infiltration of local anaesthetic directly to the sub-Tenon's space, in the inferior-nasal quadrant, using a blunt 19-gauge Southampton cannula. This method seeks to avoid the risks of retrobulbar haemorrhage, perforation of the globe, damage to the optic nerve, and injection into the subarachnoid space, whilst providing prolonged and reliable anaesthesia. Akinesia is achieved by the inferior-nasal placement of solution and if not sufficient, a top-up can easily be given. Patients graded any discomfort or pain using a 10 cm visual analogue graphical pain score chart with numerical and descriptive rating scale. The delivery of 50:50 mixture of lignocaine 2% and bupivacaine 0.5% anaesthetic was evaluated by patients with a median response of 'slight discomfort'. The operative procedure was graded with a median of 'no pain or discomfort', both for extracapsular cataract extraction and phakoemulsification. This is a new, modified, sub-Tenon technique which is simple, reliable, and which offers excellent anaesthesia and akinesia and avoids a sharp instrument being passed into the orbit.