Influence of GlideScope assisted endotracheal intubation on intraocular pressure in ophthalmic patients

Traditional Macintoch laryngoscopy is known to cause a rise in intraocular pressure [IOP], tachycardia and hypertension. These changes are not desirable in patients with glaucoma and open globe injury. GlideScope is a video laryngoscope that functions independent of the line of sight, reduces upward lifting forces for glottic exposure and requires less cervical neck movement for intubation, making it less stimulating than Macintosh laryngoscopy. The aim was to assess the variations in IOP and hemodynamic changes after GlideScope assisted intubation. After approval of the local Institutional Research and Ethical Board and informed patient consent, 50 adult American Society of Anesthesiologist I and II patients with normal IOP were enrolled in a prospective, randomized study for ophthalmic surgery requiring tracheal intubation. In all patients, trachea was intubated using either GlideScope or Macintoch laryngoscope. IOP of nonoperated eye, heart rate and blood pressure were measured as baseline, 1 min after induction, 1 min and 5 min after tracheal intubation. IOP was not significantly different between groups before and after anesthetic induction and 5 min after tracheal intubation [P = 0.217, 0.726, and 0.110 respectively]. The only significant difference in IOP was at 1 min after intubation [P = 0.041]. No significant difference noted between groups in mean arterial pressure [P = 0.899, 0.62, 0.47, 0.82 respectively] and heart rate [P = 0.21, 0.72, 0.07, 0.29, respectively] at all measurements. GlideScope assisted tracheal intubation shown lesser rise in IOP at 1 min after intubation in comparison to Macintoch laryngoscope, suggesting that GlideScope may be preferable to Macintosh laryngoscope

Three dimensional MRI study: Safety of short versus long needle peribulbar anesthesia

The standard technique of Peribulbar block is to use 25 g 25 mm needle at the junction between the lateral one third and medial two third of the lower orbital rim in the infero-temporal quadrant of the orbit. Theoretically, insertion of longer needles increases the potential of injury to important structure; however, safety of the shorter needle had never been demonstrated. This study describes the anatomy of the orbital structures with magnetic resonance imaging [MRI] using the three-dimensional constructive interference in steady state [3D CISS] sequence to present a morphological basis for needle entry at 12.5 and 25 mm lengths. Statistical comparisons were performed at the 12.5 versus 25mm depths. Statistical significance was indicated by P<0.05. Fifty patients free of orbital pathology with normal axial length were selected for MRI with the 3D CISS sequence. Original axial and multiplanar image reconstruction [MPR] images were selected for image interpretation. Orbital structures were identified at 12.5 and 25 mm depths from the orbital rim to compare significant differences in anatomy between the two imaging planes at the expected needle depth and to assess the size of the globe and the orbit. The cross sectional area of the extraocular muscles were statistically significantly smaller at the 12.5 mm plane [P = 0.001]. The area of inferotemporal fat was statistically significantly larger at the 12.5 mm plane [P = 0.033]. There was no statistical difference in the inferonasal and superonasal fat areas at different depths [P = 0.34, P = 0.35 respectively]. The size of the orbit and globe was significantly larger at 12.5 mm [P = 0.001]. There was no difference between depths in the presence or absence of neu-rovascular bundles and supporting structures including the intramuscular septae. There is a larger structure-free space at a depth of 12.5 mm than at 25 mm. Therefore, the inference is that a needle inserted in the infero-temporal zone to a depth of 12.5 mm is less likely to injure the eyeball or extra-ocular muscles than one advanced to 25 mm

Airtraq[TM] versus Macintoch laryngoscope in intubation performance in the pediatric population

Airtraq[TM] is an optical laryngoscope that allows viewing of the vocal cords without a direct line of sight. The main objective of this prospective, randomized, controlled trial was to evaluate Airtraq intubation characteristics, mainly intubation time and cardiovascular changes in the pediatric patients. Fifty children of American Society of Anesthesiologists class I, 2-10 years of age were divided into 2 groups using sealed envelope technique. Children were premedicated with midazolam. Anesthesia was induced with sevoflurane, fentanyl, and atracurium. Patients were randomly allocated to be intubated with either Airtraq [Airtraq group] or Macintosh laryngoscope [Macintosh group]. Intubation time, number of intubation attempts, optimization maneuvers, and ease of intubation were recorded. Hemodynamic variables were recorded before and after anesthetic induction, 1, 3, and 5 min after tracheal intubation. The mean age of children was 6.1 years. Compared with Macintosh group, the use of Airtraq was associated with shorter intubation time [51.6 +/- 26.7 s vs 22.8 +/- 6.1 s, respectively, P=0.001], less median number of intubation attempts 2 [1-2] versus 1 [1-1], P=0.001], more ease of intubation [2 [1-3] versus 1 [1-1], P=0.001] and less increase in the heart rate 5 min after intubation [P=0.007]. No optimization maneuvers required for Airtraq laryngoscope [P=0.001]. Airtraq decreases intubation time, number of attempts, and optimization maneuvers, less heart rate changes during intubation compared with Macintosh laryngoscope

Satisfaction level with topical versus peribulbar anesthesia experienced by same patient for phacoemulsification

Various studies have assessed patient satisfaction with topical versus peribulbar anesthesia with conflicting results. Aim of study was to determine satisfaction level in same patient who gets topical anesthesia in one eye and peribulbar block in another eye. We propose that evaluation of various indicators of patient satisfaction will enable better selection of cases for topical anesthesia in the future. Eighty patients scheduled for phacoemulsification were enrolled in prospective, randomized, double-blind study. Each patient scheduled twice for one eye under topical anesthesia and other in peribulbar block. Pain, discomfort and pressure during application of local anesthetic, during phacoemulsification and at 2 hours after procedure were assessed on standard scales. Before discharge patient satisfaction level was checked with Iowa satisfaction with anesthesia scale [ISAS]. The Student's t-test was used to determine the significance of IOWA score in both groups. P < 0.05 was considered significant. Feeling of pain, pressure and discomfort scores during administration of topical anesthesia were all significantly lower compared to peribulbar anesthesia [P=0.004, 0.000, 0.002, respectively]. In contrast, intraoperative scores were significantly higher in the topical anesthesia group compared to peribulbar anesthesia [P=0.022, 0.000, 0.000, respectively]. Patient satisfaction measured with ISAS shows that peribulbar anesthesia with P=0.000 is strongly significant. Peribulbar anesthesia provided significantly better patient satisfaction in comparison with topical anesthesia when used for cataract surgery

Comparison of levobupivacaine 0.5% or bupivacaine 0.5% both in a mixture with lidocaine 2% for superficial extraconal blockade

To evaluate the quality and efficacy of Peribulbar blockade for superficial extraconal anesthesia with levobupivacaine 0.5% versus bupivacaine 0.5%, both combined with lidocaine 2% for patients undergoing phacoemulsification. In this prospective, double blind study, 150 patients were randomly divided into two groups: group-1 received a Peribulbar block [PB] with a mixture of evobupivacaine 0.5% and lidocaine 2% while group-2 received a PB with a mixture of bupivacaine 0.5% and lidocaine 2%. The block was performed by insertion of a short needle [15 mm] in infra-temporal space just above inferior orbital notch. An initial volume of 6 9 ml of either mixture was injected until total upper eyelid drop. Akinesia score was assessed at 2, 5, and 10 min after the block. The degree of pain was assessed by a verbal rating scale immediately after block, at the end of surgery and 4 h postoperatively. The patients and surgeons were asked to rate their satisfaction level of the quality of block postoperatively. Data were analyzed with the unpaired, two-tailed t-test and the Chi-square test as appropriate. P < 0.05 was considered statistically significant. There were no significant differences between groups with respect to the akinesia score [P = 0.2] at 2, 5, and 10 min, the number of supplementary injections [P = 0.84] and initial and total required volume of local anesthetics [P = 0.80 and 0.81, respectively]. There was no significant difference between the groups regarding surgeon and patient satisfaction [P = 0.53 and P = 0.74, respectively]. Similarly the verbal rating scales assessed at three different occasions were not significantly different between the groups [P > 0.05 all cases]. The need for additional intra-operative topical anesthetic was also similar between the groups. [P = 0.69]. Superficial extra-conal block with a mixture of levobupivicaine 0.5% and lidocaine 2% or bupivicaine 0.5% and lidocaine 2% provides similar block quality and efficacy

Anesthesiologists work-related exhaustion: a comparison study with other hospital employees

Anesthesia is a demanding occupation due to long working hours, sustained vigilance, unpredictability of stressful situation, fear of litigation, competence, and production pressure. Work-related exhaustion can lead to several physical and psychological symptoms and delay decision making. The aim of this study was to evaluate how different work conditions affect personnel exhaustion by studying a sample of anesthesiologists comparing them with ophthalmologists and ancillary hospital staff One hundred fifty persons divided into three equal groups [50 each] were invited to participate in this study. Subjects were asked to answer two self report questionnaires: The Multidimensional Fatigue Inventory [MFI-20] and General Health Questionnaire [GHQ-12] which used to assess work related exhaustion and mental health, respectively. Multidimensional Fatigue Inventory scale [MFI 20] and General Health Questionnaire [GHQ 12] were significantly higher in anesthesiologists than in other groups [P=0.001]. Different aspects of work-related exhaustion showed that general, physical and mental fatigue were significantly higher in anesthesiologists [P=0.002 and 0.001, respectively]. Reduced activity and reduced motivation were also higher in anesthesiologists compare to the other groups [P=0.005 and 0.001, respectively]. Work-related exhaustion under the current study is more obvious among anesthesiologists. Ophthalmologist and ancillary hospital employees felt that they had less stress at their work

Combination therapy in the prevention of PONV after strabismus surgery in children: granisetron, ondansetron, midazolam with dexamethasone

Pediatric strabismus surgery is commonly associated with higher incidence of postoperative nausea and vomiting [PONV]. Mixture of different classes of antiemetics have been used successfully to decrease the incidence of PONV but there was no agreement on the optimal combination. The aim of this study was to investigate the effect of granisetron, ondansetron, midazolam combination with dexamethasone in the prevention of PONV following strabismus repair in pediatric population. Healthy 100 children ASA class I and II aged 4-12 years, scheduled for elective strabismus surgery, were enrolled in this study. No premedications were given anesthesia was induced by inhalational techniques using sevoflurane, nitrous oxide and oxygen mixture. After induction, fentanyl and atracurium were given and an endotracheal tube was inserted. Patients were randomly divided into four groups which received intravenously either: Placebo, or a combination of granisetron 10 micro g/kg[-1], ondansetron 50 micro g/kg[-1], midazolam 50 micro g/kg[-1], plus dexamethasone 0.5 mg/kg [-1] after induction of anesthesia and before start of surgery. All episodes of PONV during the first 24 hours anesthesia were recorded. The incidence of postoperative nausea was 48%, 8%, 12% and 0% while the incidence of vomiting was 52%, 12%, 4% and 0% in placebo, granisetron, ondansetron, midazolam and dexamethasone combination groups respectively. No difference was detected between combination groups [P value >0.05]. Prophylactic administration of either of either granisetron, ondansetron, midazolam combined with dexamethasone markedly decreases the incidence of PONV following strabismus surgery in pediatrics. All combinations are equally effective

Pain and anxiety assessment in topical vs. peribulbar anesthesia in cataract surgery

The aim of this study was to compare topical with peribulbar anesthetic technique as regards pain and anxiety in patients undergoing phacoemulsification cataract surgery. Hundred patients undergoing phacoemulsification procedure were enrolled in the study. Patients were divided into two groups, topical and peribulbar anesthesia was used for group I and II respectively. Pain assessment was done using visual analogue pain scale following administration of the local and topical anaesthesia, immediately after surgery, 2 hours postoperatively and overall pain experience. The Hamilton Anxiety Rating Scale [HARS] was used to assess the overall level of anxiety in the two studied groups. Pain score was significantly higher for Peribulbar group immediately after the block and over all pain experience [P value <0.01]. The two groups did not show any significant difference in the level of pain during the surgery and in the early post operative period. The topical group reported less perioperative anxiety compared to the Peribulbar group, but this difference did not reach significant level [P value= 0.6]. Patients undergoing phacoemulsification procedure under topical anesthesia experience less pain than patients received peribulbar blockade. Both techniques produce mild level of anxiety with less extent in topical group

Anesthetic characteristics and airway evaluation of patients with weill-marchesani syndrome

Weill-Marchesani syndrome [WMS] is a genetic connective tissue disorder associated with fibrous tissue hyperplasia. Weill-Marchesani syndrome is characterized by short stature, broad head and other facial abnormalities such as hypoplastic maxilla and distinctive ocular abnormalities. Joint stiffness is one of the features of this syndrome. We report 5 cases with classical features of WMS who were subjected to different ophthalmic procedures. To the best of our knowledge, this is the first series on the anesthetic management of this rare syndrome. We observe that patients with WMS can present for cataract, glaucoma as well as retinal surgery. Special consideration should be given to difficult intubation, cardiac abnormalities and patient positioning