Advertisement

Canadian Journal of Anaesthesia

, Volume 43, Issue 11, pp 1115–1120 | Cite as

Intravenous sedation prior to peribulbar anaesthesia for cataract surgery in elderly patients

  • David H. W. Wong
  • Pamela M. Merrick
Reports of Investigation

Abstract

Purpose

To investigate if pre-block iv sedation using midazolam, alfentanil, or a midazolam-alfentanil combination minimizes pain, reduces pain recall, and attenuates haemodynamic responses to peribulbar block; and to determine other factors influencing oxygen saturation (SpO2) following iv sedation.

Methods

In a randomized, double-blind, placebo-controlled study, 120 patients, mean age 73 yr, having cataract surgery with peribulbar anaesthesia, were randomized to receive either normal saline, 1 mg midazolam, 500 μg alfentanil, or 0.5 mg midazolam plus 250 μg alfentanil. Blood pressure (BP), heart rate (HR) and pulse oximetry readings were recorded before injection of the study drugs, immediately after completion of the peribulbar block, and 10 min after the block. Pain from the anaesthetic block was assessed immediately after the block and after surgery using a visual analog scale, and recall of pain was assessed by telephone on the day after surgery.

Results

Pain scores were low in all four groups. Midazolamalfentanil reduced pain perception, and all iv sedation used reduced pain recall. Midazolam reduced systolic BP; alfentanil ± midazolam reduced HR. All iv sedation reduced SpO2 more than did saline, but not usually to a clinically important level. Nine patients had a SpO2 S 90%; all had received alfentanil with or without midazolam. It was not possible to predicoxygen saturation levels by any factors other than iv sedation and baseline SpO2 levels.

Conclusion

Intravenous sedation with midazolam or alfentanil or in combination reduced pain perception, pain recall, and haemodynamic responses from peribulbar anaesthesia. Fifteen percent of patients given alfentanil developed clinically important oxygen desaturation. The use of fine gauge needles combined with slow injection of anaesthetic solution causes minimal discomfort, and routine iv sedation may be unnecessary.

Key words

Anaesthesia: local, peribulbar block Sedation: intravenous, midazolam, alfentanil Complications: pain, discomfort, haemodynamic responses, oxygen desaturation, recall 

Résumé

Objectif

Étudier si, avant un bloc péribulbaire, la sédation iv au midazolam, à l’alfentanil ou à la combinaison midazolamalfentanil diminue la douleur, réduit son évocation et atténue les réponses hémodynamiques; déterminer si d’autres facteurs que la sédation iv influencent la saturation en oxygène (SpO2).

Méthodes

Au cours d’une étude aléatoire, en double aveugle et contrôlée par placebo, 120 patients âgés en moyenne de 73 ans subissant une intervention pour cataracte sous anesthésie péribulbaire ont été répartis pour recevoir soit du sol physiologique, du midazolam 1 mg, de l’alfentanil 500 μg ou du midazolam 0,5 mg associé à 250 μg d’alfentanil. La pression artérielle (PA), la fréquence cardiaque (FC) et l’oxymétrie de pouls ont été enregistrées avant l’injection des produits à l’étude, immédiatement après la complétion du bloc péribulbaire et dix minutes plus tard. La douleur associée au bloc était évaluée sur une échelle visuelle analogique immédiatement après le bloc et après l’intervention. L’évocation de la douleur était cotée au téléphone un jour après l’intervention.

Résultats

Les scores de douleur étaient bas pour les quatre groupes. Le midazolam-alfentanil a réduit la perception de la douleur et tous les produits ont diminué son évocation. Le midazolam a fait baisser la TA; l’alfentanil ± midazolam a ralenti la FC. Tous les produits ont réduit la SpO2 plus que le sol. physiologique mais, en général, à un niveau cliniquement sans importance. Neuf patients ont présenté une SpO2 < - 90% et tous avaient reçu de l’alfentanil avec ou sans midazolam. Il a été impossible de prédire le niveau de saturation en oxygène par d’autres facteurs que la sédation iv et le niveau initial de la SpO2.

Conclusion

La sédation intraveineuse au midazolam, à l’alfentanil ou à leur association diminue la perception de la douleur, son évocation et les réponses hémodynamiques provoquées par l’anesthésie péribulbaire. Quinze pour cent des patients sous alfentanil se sont désaturés de façon cliniquement importante. L’utilisation d’aiguilles fines associée et le lenteur de l’injection de la solution anesthésique permettent de diminuer la souffrance provoquée par le bloc; une sédation iv systématique n’est pas absolument nécessaire.

References

  1. 1.
    Spencer MF. Extracapsular cataract and lens implant surgery in developing countries: keeping it simple. Ophthalmic Surgery 1990; 21: 447–52.PubMedGoogle Scholar
  2. 2.
    Quist LH, Stapleton SS, McPherson SD Jr. Preoperative use of the Honan intraocular pressure reducer. Am J Ophthalmol 1983; 95: 536–8.PubMedGoogle Scholar
  3. 3.
    Smith PH, Kemp P, Smith ER. A comparison of retrobulbar block produced by etidocaine 1% and by a mixture of lidocaine 2% and bupivacaine 0.75%. Ophthalmic Surgery 1987; 18: 106–10.PubMedGoogle Scholar
  4. 4.
    Palay DA, Stulting RD. The effect of external ocular compression on intraocular pressure following retrobulbar anesthesia. Ophthalmic Surgery 1990; 21: 503–7.PubMedGoogle Scholar
  5. 5.
    Cheng KP, Larson CE, Biglan AW, D’Antonio JA. A prospective, randomized, controlled comparison of retrobulbar and general anesthesia for strabismus surgery. Ophthalmic Surgery 1992; 23: 585–90.PubMedGoogle Scholar
  6. 6.
    Fiore PM, Cinotti AA. Systemic effects of intraocular epinephrine during cataract surgery. Annals of Ophthalmology 1988; 20: 23–5.PubMedGoogle Scholar
  7. 7.
    Sabo B, Smith RB, Gilbert TJ. Evaluation of rebreathing in patients undergoing cataract surgery. Ophthalmic Surgery 1988; 19: 249–51.PubMedGoogle Scholar
  8. 8.
    Zahl K, Jordan A, McGroarty J, Sorensen B, Gotta AW. Peribulbar anesthesia. Effect of bicarbonate on mixtures of lidocaine, bupivacaine, and hyaluronidase with or without epinephrine. Ophthalmology 1991; 98: 239–42.PubMedGoogle Scholar
  9. 9.
    Sarvela J, Nikki P. Hyaluronidase improves regional ophthalmic anaesthesia with etidocaine. Can J Anaesth 1992; 39: 920–4.PubMedGoogle Scholar
  10. 10.
    Salmon JF, Mets B, James MF, Murray AD. Intravenous sedation for ocular surgery under local anaesthesia. Br J Ophthalmol 1992; 76: 598–601.PubMedCrossRefGoogle Scholar
  11. 11.
    Virkkila ME, Ali-Melkkila TM, Kanto JH. Premedication for outpatient cataract surgery: a comparative study of intramuscular alfentanil, midazolam and placebo. Acta Anaesthesiol Scand 1992; 36: 559–63.PubMedCrossRefGoogle Scholar
  12. 12.
    Nuotto EJ, Korttila KT, Lichtor JL, Östman PL, Rupani G. Sedation and recovery of psychomotor function after intravenous administration of various doses of midazolam and diazepam. Anesth Analg 1992; 74: 265–71.PubMedGoogle Scholar
  13. 13.
    White PF, Negus JB. Sedative infusions during local and regional anesthesia: a comparison of midazolam and propofol. J Clin Anesth 1991; 3: 32–9.PubMedCrossRefGoogle Scholar
  14. 14.
    Rosland JH, Hole K. 1,4-Benzodiazepines antagonize opiate-induced antinociception in mice. Anesth Analg 1990; 71: 242–8.PubMedCrossRefGoogle Scholar
  15. 15.
    Coulthard P, Rood JP. An investigation of the effect of midazolam on the pain experience. Br J Oral Maxillofac Surg 1992; 30: 248–51.PubMedCrossRefGoogle Scholar
  16. 16.
    Ho ET, Parbrook GD, Still DM, Parbrook EO. Memory function after i.v. midazolam or inhalation of isoflurane for sedation during dental surgery. Br J Anaesth 1990; 64: 337–40.PubMedCrossRefGoogle Scholar
  17. 17.
    Richards A, Griffiths M, Scully C. Wide variation in patient response to midazolam sedation for outpatient oral surgery. Oral Surgery, Oral Medicine, Oral Pathology 1993; 76: 408–11.CrossRefGoogle Scholar
  18. 18.
    Reinsel RA, Veselis RA, Heino R, Miodownik S, Alagesan R, Bedford RF. Effect of midazolam on the auditory event-related potential: measures of selective attention. Anesth Analg 1991; 73: 612–8.PubMedCrossRefGoogle Scholar
  19. 19.
    Ferrari LR, Donlon JV. A comparison of propofol, midazolam, and methohexital for sedation during retrobulbar and peribulbar block. J Clin Anesth 1992; 4: 93–6.PubMedCrossRefGoogle Scholar
  20. 20.
    Zacharias M, Luyk NH, Parkinson RT. Oxygen saturation during intravenous sedation using midazolam. New Zealand Dental Journal 1992; 88: 94–6.PubMedGoogle Scholar
  21. 21.
    van der Bijl P, Roelofse JA, Joubert JJ, van Zyl JF. Comparison of various physiologic and psychomotor parameters in patients sedated with intravenous lorazepam, diazepam, or midazolam during oral surgery. J Oral Maxillofac Surg 1991; 49: 672–8.PubMedCrossRefGoogle Scholar
  22. 22.
    Lewis P, Hamilton RC, Brant R, Loken RG, Maltby JR, Strunin L. Comparison of plain with pH-adjusted bupivacaine with hyaluronidase for peribulbar block. Can J Anaesth 1992; 39: 555–8.PubMedGoogle Scholar

Copyright information

© Canadian Anesthesiologists 1996

Authors and Affiliations

  • David H. W. Wong
    • 1
  • Pamela M. Merrick
    • 1
  1. 1.Department of AnaesthesiaUniversity of British ColumbiaVancouverCanada

Personalised recommendations