Prospective evaluation of anesthetic protocols during pediatric ophthalmic surgery

Abstract

Purpose: To date, no protocol of anesthesia for pediatric ophthalmic surgery is unanimously recognized. The primary anesthetic risks are associated with strabismus surgery, including oculocardiac reflex, postoperative nausea and vomiting, and postoperative pain. Methods: This was a prospective, monocentric, observational study conducted in a tertiary pediatric ophthalmic unit. Our anesthetic protocol for strabismus surgery included postoperative nausea and vomiting prevention using dexamethasone and ondansetron. No drug-based prevention of oculocardiac reflex or local/locoregional anesthesia was employed. Results: A total of 106 pediatric ophthalmic surgeries completed between November 2015 and May 2016 were analyzed. The mean patient age was 4.4 (range: 0.2–7.3, standard deviation: 2.4) years. Ambulatory rate was 90%. Oculocardiac reflex incidence was 65% during strabismus surgery (34/52), 50% during congenital cataract surgery (4/8), 33% during intramuscular injection of botulinum toxin (1/3), and 0% during other procedures. No asystole occurred. Postoperative nausea and vomiting incidence was 9.6% after strabismus surgery (5/52) and 0% following the other procedures. One child was hospitalized for one night because of persistent postoperative nausea and vomiting. Postoperative pain generally occurred early on in the recovery room and was quickly controlled. Its incidence was higher in patients who underwent strabismus surgery (27%) than in those who underwent other procedures (9%). Conclusion: Morbidity associated with ophthalmic pediatric surgery is low and predominantly associated with strabismus surgery. The benefit–risk ratio and cost-effectiveness of oculocardiac reflex prevention should be questioned. Our postoperative nausea and vomiting rate is low, thanks to the use of a well-managed multimodal strategy. Early postoperative pain is usually well-treated but could probably be more effectively prevented.

The Oculocardiac Reflex: A Review

“… 25 Ducloyer et al noted 27% post-op pain with strabismus and only 9% with other eye procedures including Botox injection and cataract. 139 Postoperative pain and PONV was no different between strabismus patients whether or not they had −33% OCR. 86 …”

“… 118 Dexamethasone with or without ondansetron has been used to reduce PONV. 139 Slow infusion dexmedetomidine may reduce PONV after strabismus surgery in children. 84 …”

Anesthetic Impacts on the Oculocardiac Reflex: Evidence from a Large, Observational Study

“…In another report, OCR was common (65%) in strabismus surgery with dexamethasone and ondansetron. 27 There was a trend for reduced oculocardiac reflex with deeper inhalational anesthesia -at least with isoflurane, halothane and sevoflurane. This concentration effect occurred during the initial OCR and also the difference in agent concentration impacting the difference between first and second measured OCR in the case.…”

“…In another report, OCR was common (65%) in strabismus surgery with dexamethasone and ondansetron. 27 …”

Anesthesia in Pediatric Eye Surgery (Review)

“…The active development of eye microsurgery within the last decade, undoubtedly, requires improvement of anesthetic support in such interventions. The specifics of anesthesia in the pediatric eye surgery is based on solution of such problems as sufficient sedation, effective intra-and postoperative analgesia, prevention of adverse reflex reactions (oculocardiac, laryngeal), relief of postoperative nausea and vomiting (PONV), and prevention of postanesthesia agitation [1][2][3][4][5][6][7][8][9][10][11][12].…”