Trifascicular block with syncope triggered by preoperative mydriatic eye drops for cataract surgery.

We report the case of an 85-year-old patient who developed trifascicular block with syncope, triggered by preoperative eye drops for cataract surgery. This life-threatening situation reopens the debate over the necessity of having an anesthesiologist present during cataract surgery.

[Prevalence and causes of pain after cataract surgery: Comparison of 1st and 2nd eyes]. / Analyse de la douleur et ses déterminants après chirurgie de cataracte : comparaison de l'intervention du 1er et du 2e œil.

INTRODUCTION: In our practice, patients undergoing bilateral cataract surgery complain of more significant pain after the 2nd eye surgery. The goal of this study was to compare postoperative pain between the 1st and 2nd eyes with cataract surgery under topical anesthesia and to identify the causes of this pain. PATIENTS AND METHODS: We conducted a prospective observational study between May and September 2015. We included 69 consecutive adults scheduled for bilateral cataract surgery under topical anesthesia within 2 months by the same surgeon. A self-assessment questionnaire of anxiety (the Amsterdam Preoperative Anxiety and Information Scale [APAIS]) was completed before each procedure. Postoperative pain was assessed by the visual analogue scale (VAS) in the recovery room. RESULTS: Among the 69 included patients (mean age: 70±1.3 years), 13 (19%) experienced more pain after the 2nd eye procedure. The median VAS was 0 (EI: 0-1) after the first eye versus 0 (EI: 0-2) after the second eye (P=0.836). The patients with the most pain after the second eye surgery had a median anxiety score of 5 (EI: 4 to 9.5), which was comparable to those without pain (P=0.589). On bivariate analysis, women had more pain after second eye surgery (27%) than men (4%) (P=0.026). However, this association lost its significance when the analysis was adjusted for the level of anxiety (adjusted OR 7.7, 95% CI [0.91; 64.6]). In fact, women were more anxious [median anxiety score of 6 (EI: 4 to 8.5)] before 2nd eye surgery than men [median score: 4 (EI: 4-6); P=0.013]. DISCUSSION: Pain levels appeared to be very moderate on both sides when measured postoperatively, as opposed to statements often made in the immediate postoperative period. There is a discrepancy with the literature data. However, each study had small sample sizes. CONCLUSION: We did not find any significant difference in pain between 1st and 2nd eye cataract surgery under topical local anesthesia. While postoperative pain appeared greater among women, we have noted the possible influence of anxiety, which could justify specific preoperative support.

HypnosIS to faciLitate trans-Esophageal echocardiograPhy Tolerance: The I-SLEPT study.

BACKGROUND: Trans-oesophageal echocardiography (TOE) is one of the major diagnostic tests in cardiovascular medicine, but the procedure is associated with some discomfort for the patient. AIM: To determine the additive value of hypnosis as a means of improving patient comfort during TOE. METHODS: We randomly assigned 98 patients with non-emergency indications for TOE to a 30-minute hypnosis session combined with topical oropharyngeal anaesthesia (HYP group) or topical oropharyngeal anaesthesia only (CTRL group) before the procedure. The primary efficacy endpoint was the level of patient discomfort assessed using a visual analogue scale (VAS). RESULTS: The VAS score was significantly reduced in the HYP group compared with the CTRL group (6 [5; 8] vs. 7 [5; 9]; P=0.046). No statistically significant differences were observed in terms of procedure failure (HYP group 2.2% vs. CTRL group 3.9%; P=1.00) and procedure length (HYP group 7 [5; 11] minutes vs. CTRL group 8 [7; 11] minutes; P=0.29). However, the patients' subjective estimations of the length of the procedure were significantly shorter in the HYP group than in the CTRL group (8 [5; 10] vs. 10 [10; 20] minutes; P<0.0001). There were no major adverse events in either group. The reported minor events rate was lower in the HYP group (36% vs. 57%; P=0.04). CONCLUSION: Hypnosis is an efficient alternative or complementary method for improving patient comfort during TOE.

[Assessment of anesthesiologist intervention during cataract surgery under topical anesthesia]. / Évaluation du recours à l'anesthésiste-réanimateur lors de la chirurgie de la cataracte réalisée sous anesthésie topique.

OBJECTIVES: The current demographic situation in France regarding anesthesiologists calls for a reconsideration of anesthesia management for patients undergoing cataract surgery under topical anesthesia. This prospective observational study aimed to assess the requirement for anesthesiologist intervention during cataract surgery performed under topical anesthesia. PATIENTS AND METHODS: Patients operated between November 2, 2011 and July 31, 2012 were included after indication of topical anesthesia for phacoemulsification proposed by the surgeon and confirmed by the anesthesiologist. Each patient was premedicated. All patients were monitored and supervised during the surgery by a nurse anesthesiologist. An anesthesiologist could be called at any time at the request of the surgeon or nurse anesthesiologist. For each patient, medical histories were recorded as well as the event "anesthesiologist called", along with the reason and the treatment performed. RESULTS: Five hundred and seventy-five phacoemulsifications were performed in 486 patients. The event "anesthesiologist called" was recorded 20 times: 18 times for hypertension, once for anxiety and once for non-emergent conversion to general anesthesia after a surgical complication. Each episode of hypertension was successfully treated by following the nicardipine protocol. Preoperatively uncontrolled hypertension was the only significant predictive risk factor for anesthesiologist requirement. CONCLUSIONS: These results question the usefulness of preoperative anesthesia consultation for all patients who underwent phacoemulsification under topical anesthesia, since this consultation does not lead to an anesthesiologist service. Intraoperative medical complications may be treated according to medical protocols developed jointly by surgeons and anesthesiologists. This practice may free up anesthesiologists' time, without compromising patient safety.

[Simplified topical anesthesia protocol for ambulatory cataract surgery: safety and patient and surgeon satisfaction]. / Étude de satisfaction et de sécurité d'un protocole d'anesthésie simplifié pour la chirurgie de cataracte sous anesthésie topique.

BACKGROUND AND PURPOSE OF STUDY: The purpose of our study was to assess safety and efficacy of cataract surgery (CS) under topical anesthesia alone, i.e. without pre-anesthetic evaluation and without direct presence of an anesthesiologist. To this end we assessed the incidence of patients' preoperative anxiety, perioperative adverse events and patients' and surgeons' satisfaction. MATERIALS AND METHODS: Patients undergoing CS under topical anesthesia over a one-month period were included. An anesthesiologist and nurse anesthetist were present in the area and could intervene in case of an adverse event. Patients' anxiety was scored using the Amsterdam Preoperative Anxiety & Information Scale (APAIS), and their satisfaction with the Iowa Satisfaction with Anesthesia Scale (ISAS). Surgeons' satisfaction was scored with a VAS from 0 to 10 (0: surgery not possible & 10: excellent surgical conditions). RESULTS AND DISCUSSION: One hundred and twenty-four consecutive patients were included; mean age was 71 (±9.4) years. Mean APAIS I was 6.4/20 (±3.7). Mean APAIS II was 3.1 (±1.8). Mean ISAS score was 5.5/6 (±0.6), indicating high patient satisfaction. Surgeon satisfaction score was 8.9/10 (±1.7). Twenty-three adverse events occurred of which 16 required interventions by the anaesthesiologist or surgeon: 5 supplemental local or regional anaesthesia, 6 iv-analgesia, 5 management of hypertension. CONCLUSION: These preliminary data suggest that a simplified topical anesthesia protocol for ambulatory CS appears to be feasible and safe, as long as an anesthesia team is present in the area to intervene if needed.

[Evaluation of preoperative anxiety in patients requiring glaucoma filtration surgery]. / Évaluation de l'anxiété préopératoire chez les patients nécessitant une chirurgie filtrante du glaucome.

PURPOSE: Preoperative anxiety is often expressed by patients requiring filtration surgery for their glaucoma. So far, there has been no scale for screening this group of patients for preoperative anxiety. The Amsterdam Preoperative Anxiety and Information Scale (APAIS) is a self-evaluation questionnaire which has been used in specialties other than ophthalmology and which makes it possible to identify the adult patients with a high level of preoperative anxiety over an upcoming surgical procedure. The purpose of this study is to estimate the preoperative anxiety in glaucoma patients requiring filtration surgery. METHODS: We performed a prospective study of 36 adult patients with chronic glaucoma not responding to medical treatment and who were about to undergo filtration surgery (trabeculectomy or deep sclerectomy). The APAIS questionnaire was given to the patients after discussing the indication for surgery. A global anxiety score (ranging from 4 to 20) above 10 defined patients with a high level of preoperative anxiety. We attempted to identify among these patients the factors related to filtration surgery which caused them anxiety (lack of control of intraocular pressure, risk of blindness, presence of the filtering bleb). RESULTS: In our sample of patients, we found that glaucoma was a source of anxiety. That was also true for the surgical procedure, though most patients believe that once the decision had been made, their psychological status was not modified by the upcoming procedure. DISCUSSION: The patient-clinician relationship is important in any chronic disease, all the more so in glaucoma, since this disease remains asymptomatic for a long time. When filtration surgery is necessary, the patients are going to express less preoperative anxiety if they trust their physician and if individualized information has been given to them CONCLUSION: The French version of the APAIS is a quick scale, easily completed, that can be recommended for evaluating anxiety and patients' need for information prior to filtering surgery. It is usually easier for the surgeon to find ways to reduce the patient's anxiety if a relationship of trust has been established between the two.