Remifentanil-ketamine versus fentanyl-ketamine sedation in patients undergoing phacoemulsification with topical anesthesia: comparison of intraocular pressure changes and sedation quality

Narcotics and sedatives can reduce intraocular pressure. This study was performed to evaluate the effect of remifentanil plus ketamine on intraocular pressure and sedation quality in comparison with fentanyl plus ketamine during and after operation in patients undergoing phacoemulsification with topical anesthesia. Forty four patients were randomized into two groups to receive either a continuous infusion of remifentanil [0.2 micro g/kg/min for 4 min and then 0.1 micro g/kg/min: Group R, n=22] or bolus intravenous fentanyl [1.5 micro g/kg: Group F, n=22] for sedation. Patients in both groups received low dose ketamine [0.15 mg/kg] intravenously. Topical anesthesia was performed using tetracaine 0.5% eye drop in both eyes. Intraocular pressure was measured in non-operative eye before sedation [baseline], 2 minutes after sedation, before intraocular lens insertion, at the end of operation and 15 minutes after the end of operation using Schiotz tonometer. Sedation, cooperation, satisfaction and pain scores and also postoperative nausea and vomiting were recorded in all patients. Surgeon satisfaction scores were evaluated at the end of operation. The intraocular pressure did not differ significantly between the two groups throughout the study. The mean [SD] intraocular pressures 2 minutes after sedation, before intraocular lens insertion, at the end of operation and 15 minutes after the end of operation in recovery room were all less than that of baseline in both groups, but the baseline value was decreased only significantly [P<0.05] in recovery room [13.75 [3.46] to 11.91 [3.43] in group R, respectively and 13.74 [3.05] to 11.57 [2.33] in group F, respectively]. The incidence of postoperative nausea and vomiting in group R was higher than that of group F [7 patients in group R and no patient in group F, P=0.009]. Combination of remifentanil infusion and intravenous ketamine did not offer any advantages over the combination of intravenous fentanyl and ketamine in order to prevent intraocular pressure rising during phacoemulsification. The lower incidence of postoperative nausea and vomiting and higher rate of appropriate sedation in fentanyl group suggested fentanyl as a more suitable medication for systemic sedation compared with remifentanil

Influence of pre-emptive versus preventive analgesia with oral aetaminophen on postoperative pain in painful ophthalmic surgeries: which one is better?

Patients undergoing certain ophthalmic operation are more likely to experience serious postoperative pain. This study was carried out to evaluate the effects of pre-emptive vs. preventive analgesia with oral acetaminophen on postoperative pain in painful ophthalmic surgeries. In a double blind clinical trial, 60 patients undergoing strabismus, retinal detachment or deep vitrectomy were randomized into three equal groups. The first group [G1] received oral acetaminophen one hour before induction of general anesthesia and placebo postoperatively. The second group received placebo before induction and acetaminophen after the operation [G2]. The third group received placebo at both times [G3]. Blood pressure, heart rate and occurrence of oculocardiac reflex [OCR] were recorded during the operation. Pain score [VAS: visual analog scale], the time of the first analgesic use [in hours], and total analgesic requirement [acetaminophen: mg] were determined until 24 hours postoperatively. Data was analyzed using ANOVA, Chi-2 and Kruskal-Wallis tests. The mean pain score was lower in G1 compared with G2 at 2 and 24 hours after the operation [2.1 +/- 0.6 vs. 2.7 +/- 0.4, P=0.001 and 1.1 +/- 0.3 vs. 1.5 +/- 0.5, P=0, respectively]. The pain score at 2, 6 and 24 hours after the operation was greater in G3 compared with G1 [2.8 +/- 0.3 vs. 2.1 +/- 0.6, P=0, 2.3 +/- 0.7 vs. 1.7 +/- 0.5, P=0 and 1.6 +/- 0.4 vs. 1.1 +/- 0.3, P=0.001, respectively]. There was no significant difference among the three groups with respect to the intraoperative hemodynamic changes, occurrence of OCR, the time of the first analgesic use and analgesic consumption. The use of oral acetaminophen as pre-emptive analgesia one hour before painful ophthalmic surgeries may reduce postoperative pain intensity

Preoperative sub-tenon block decreases perioperative pain severity and adveres complications

This study was designed to evaluate the efficacy of sub-tenon block [preemptive analgesia] after general anesthesia and before beginning the repair of retinal detachment [RD] surgery by using scleral buckle and cryopexy. Sixty eight patients scheduled for RD surgical repair with "American Society of Anesthesiologists" [ASA] I or II were included in this clinical trial study. The patients were randomly and blindly divided into two equal groups. The surgery was done under general anesthesia in both groups, but in the case group, sub-tenon block was given as preemptive analgesia after the induction of general anesthesia with similar methods and before the start of surgery. The incidences of intra and postoperative [up to 24 hours] oculocardiac reflex [OCR], ischemic heart disease [IHD] changes, nausea and vomiting [PONV], delirium, total analgesic drug consumption and ocular severity of pain were significantly lower in the case group compared with the control group [p<0.05]. Mean blood pressure, heart rate, time of discharge from the hospital, frequency of requirement to analgesic drug, intra and postoperatively were significantly lower in the case group compared with the control group [p<0.05]. According to this research, the use of sub-tenon block in RD surgery effectively reduces PONV, postoperative pain, analgesic drug requirements, delirium, discharge time from the hospital, IHD, hemodynamic changes and OCR, therefore it is recommended for daily routine ophthalmologic surgeries