Evaluation of magnesium sulfate as an adjuvant in sub-Tenon anesthesia for cataract surgery: A prospective, randomized controlled trial.

Purpose: To evaluate the efficacy, safety, and satisfaction for the use of adjuvant; magnesium sulfate (MgSO4) in sub-Tenon anesthesia for cataract surgery. Methods: This single centered randomized, double blind trial was held in 2021 after approval of ethical committee at the Eye Hospital, Riyadh, Saudi Arabia. Cataract patients to be operated using local anesthesia were randomly assigned to two groups; Group magnesium sulfate (MS) received 50 mg/0.5 ml of magnesium sulfate and Group normal saline (NS) received 0.5 ml of normal saline added to the standard mixture, respectively. Absence of eyelid dropping and akinesia of the globe at different time after anesthesia were considered as ineffective anesthesia. The age and sex-adjusted generalized estimating equation (GEE) analysis was carried out. Complications, patient's and surgeon's satisfaction were also compared. Results: Each group had 100 cataract patients. Effectiveness of block was not significantly different in two groups (adjusted odds ratio, 0.90; 95% confidence interval [CI], 0.62, 1.31; P = 0.594). The likelihood of "no eye-opening" significantly increased with time (adjusted odds ratio, 1.26; 95% CI, 1.18-1.34; P < 0.001). Subconjunctival bleeding was significantly higher in the MS versus NS Group (36 of 98 [36.7%] vs. 11 of 102 [10.8%], P < 0.001). Chemosis was not significantly different between the groups (P = 0.95). Patient's satisfaction score was very good (9/10) but slightly higher in NS group than MS (P = 0.001) while surgeon's satisfaction score was similar in both groups (P = 0.149). Conclusions: Although safe, adding 50 mg of magnesium sulfate did not improve the effect of sub-Tenon anesthesia for cataract surgery. Risk of subconjunctival bleeding was higher in cataract patients operated using MgSO4 compared to those managed with the conventional sub-Tenon anesthetic.

Genetic Variants of MIR27A, MIR196A2 May Impact the Risk for the Onset of Coronary Artery Disease in the Pakistani Population.

Genetic variants in microRNA genes have a detrimental effect on miRNA-mediated regulation of gene expression and may contribute to coronary artery disease (CAD). CAD is the primary cause of mortality worldwide. Several environmental, genetic, and epigenetic factors are responsible for CAD susceptibility. The contribution of protein-coding genes is extensively studied. However, the role of microRNA genes in CAD is at infancy. The study is aimed to investigate the impact of rs895819, rs11614913, and rs2168518 variants in MIR27A, MIR196A2, and MIR4513, respectively, in CAD using allele-specific PCR. Results: For variant rs11614913, significant distribution of the genotypes among the cases and controls was determined by co-dominant [χ2 = 54.4; p value ≤ 0.0001], dominant (C/C vs. C/T + T/T) [OR = 0.257 (0.133-0.496); p value ≤ 0.0001], recessive (T/T vs. C/T + C/C) [OR = 1.56 (0.677-0.632); p value = 0.398], and additive models [OR = 0.421 (0.262-0.675); p value = 0.0004]. Similarly, a significant association of rs895819 was determined by co-dominant [χ2 = 9.669; p value ≤ 0.008], dominant (A/A vs. A/G + G/G) [OR = 0.285 (0.1242-0.6575); p value ≤ 0.0034], recessive (G/G vs. A/G + A/A) [OR = 0.900 (0.3202-3.519); p value = 1.000], and additive models [OR = 0.604 (0.3640-1.002); p value = 0.05] while no significant association of rs2168518 with CAD was found. Conclusion: The variants rs895819 and rs11614913 are the susceptibility factors for CAD.

Anesthesia management of ophthalmic surgery for patient with suspected/confirmed COVID-19 -Saudi Anesthesia Society guidelines.

The outbreak of the novel coronavirus (COVID-19) has been declared a global pandemic. With a mortality rate reaching up to 5%, healthcare professionals treating patients with COVID-19 are at a significantly higher risk for exposure themselves. Given the rapidly progressing rate of COVID-19, there is an urgent need for developing guidelines within each specialty. This article discusses guidelines specifically for anesthesiologists dealing with ophthalmic surgeries with suspected or confirmed COVID-19 patients. Anesthesiologists always work in the proximity of the patient's face while performing either ocular regional anesthesia or while managing the airway in the process of intubation/extubation. Within these guidelines, the emphasis is provided on thorough preoperative screening to identify COVID-19 patients and to prevent the exposure of healthcare staff by following standard personal protective equipment (PPE) precautions.

Comparison of topical oxybuprocaine and intravenous fentanyl in pediatric strabismus surgery.

PURPOSE: To compare the outcomes such as postoperative nausea/vomiting, analgesic requirements, and hospital stay following the use of topical oxybuprocaine hydrochloride 0.4% or intravenous (IV) fentanyl in children undergoing strabismus surgery. METHODS: This was a prospective cohort study. Children operated under general anesthesia for strabismus were given topical oxybuprocaine hydrochloride 0.4% (Group T) and IV fentanyl (Group F) before surgery. The episodes of nausea/vomiting, pain score, requirement of additional analgesia during postoperative period, and duration of hospital stay were compared in two groups. RESULTS: There were 47 children in Group T and 59 children in Group F. The median pain score in two groups were 2.38 (25% quartile; 2.0) and 3.00 (25% quartile; 3.00), respectively. The difference was significant (K W P < 0.03). The episodes of nausea/vomiting in two groups were in 2 and 6 children in Group T and Group F, respectively. The median hospital stay of children of Group T and Group F were 242 and 285 min, respectively. The difference was not statistically significant (P = 0.22). CONCLUSIONS: Using intraoperative topical oxybuprocaine drops, one can achieve better analgesic outcomes and reduce risk of nausea and vomiting compared to intravenous opioid analgesics and therefore, the hospital stay could also be marginally reduced.

Comparison of Olive Tipped and Conventional Steven's Cannula for Sub-Tenon Ophthalmic Anesthesia.

PURPOSE: To compare the efficacy of the olive tipped (OT) cannula to the conventional Steven's cannula for sub-Tenon block (STB) before cataract surgery. METHODS: This prospective, randomized, double-masked compared STB delivered in cataract surgery patients with an OT cannula or a conventional Steven's cannula (ST). Outcome variables included the akinesia score and lid movement scores at 5 and 10 min. The patient perception of pain during delivery of the STB and surgery were also compared between groups. Surgeon satisfaction with anesthesia was compared between groups. P <0.05 was statistically significant. RESULTS: There were sixty patients in each group. The age between groups was not statistically different (P = 0.4). The body mass index was higher in the ST group compared to the OT group (P < 0.001). The akinesia score at 5 and 10 min did not differ between groups (P = 0.07 and P = 0.6, respectively). The patient perception of pain during STB and surgery were similar between groups (P = 0.1 and P = 0.06, respectively). There were six patients with mild chemosis and redness in the OT group and 15 patients in the ST group. CONCLUSION: An OT cannula is equally effective as the conventional Steven's cannula for delivering STB anesthesia before cataract surgery.

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

BACKGROUND: 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. AIM: The aim was to assess the variations in IOP and hemodynamic changes after GlideScope assisted intubation. MATERIALS AND METHODS: 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. RESULTS: 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. CONCLUSION: 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.

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

PURPOSE: 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. MATERIALS AND METHODS: 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. RESULTS: 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). CONCLUSIONS: 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.

A novel method for laryngeal mask airway size selection in paediatric patients.

CONTEXT: The successful use of the laryngeal mask airway in children partly depends on the correct selection of size. Most anaesthesiologists rely on the weight-based table which is often difficult to remember. A simple method allowing an adequate choice of the correct size may be highly desirable. OBJECTIVES: To test the hypothesis that the size of the external ear (pinna) of the child may be used as proxy for the required size of laryngeal mask airway. DESIGN: A descriptive study. SETTING: King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia. PATIENTS: Two hundred and ten paediatric patients aged 6 months to 15 years, of either sex, American Society of Anesthesiologists (ASA) 1-2 and scheduled for routine ophthalmological procedures from 1 March to 31 December 2010. Emergency cases, patients with a full stomach or with a history of any oropharyngeal lesion other than tonsillar hypertrophy were excluded. MAIN OUTCOME MEASURES: The size of the external ear was measured with a ruler in vertical and horizontal dimensions in the first 30 patients, and visually evaluated for the remaining patients. For all, the nearest corresponding size of partially inflated laryngeal mask airway was chosen and inserted after induction. The correct placement was assessed using predefined criteria. RESULTS: Insertion and good ventilation was achieved in 196 (93.3%) on first attempt. Fourteen patients (6.7%) required a second attempt and the main reason for failure was an audible leak because of smaller size. CONCLUSION: Choosing the size of the laryngeal mask airway in children according to the size of the external ear was associated with a success rate of 93% which is comparable with that reported in the literature when the tables are used. This simple method may allow a rapid choice of the correct size of laryngeal mask airway and may eliminate the need to remember different tables or formulae.

Periocular hematoma secondary to subperiosteal injury by a short needle.

Bleeding and intraorbital hematoma is one of the most common complications of needle block for ophthalmic local anesthesia. We describe an unusual presentation of hematoma that originated in the subperiosteal space and extended to the subconjunctival and periocular area after a peribulbar block for phacoemulsification in a 55-year-old lady. It required an urgent surgical evacuation in order to reduce the intraocular pressure and save the eye. Detailed management to improve the outcome is discussed.

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

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSION: Peribulbar anesthesia provided significantly better patient satisfaction in comparison with topical anesthesia when used for cataract surgery.

The effects of duration of Propofol injection on hemodynamics.

OBJECTIVES: The aim of study was to see whether increasing the time of injection of standard dose of Propofol during induction can prevent fall in blood pressure in female patients; as is commonly observed with this anesthetic agent. DESIGN: Comparative, non-interventional, prospective, and randomized and single blind study. PLACE AND DURATION: The study was carried out on female in-patients admitted and surgically operated at a specialized, tertiary care hospital and was completed with in 6-months. PATIENTS AND METHODS: The hemodynamic effects of Propofol were compared in three groups of patients undergoing minor surgical procedures. Each group comprised of 25 patients. A 2 mg/kg Propofol was administered for 30, 60 and 120 seconds in patients of group-A, group-B and group-C respectively. Baseline heart rate, systolic blood pressure, diastolic blood pressure and mean arterial blood pressures were recorded before induction of anesthesia. The same hemodynamic variables were recorded after induction at one-minute intervals for 10-minutes. Anesthesia was maintained with 1.5% enflurane and 60% nitrous oxide in oxygen. Complications such as pain on injection, dystonic movements, erythema, laryngeal spasm, episodes of desaturation, hypoventilation and the number of additional boluses required to induce hypnosis were also recorded. RESULTS: The fall in blood pressure was statistically insignificant between the three groups of patients. The incidence of dystonic movements was the highest in group-A while pain on injection was highest in group-C. Additional boluses of Propofol to induce hypnosis were required for patients in group-B and group-C. CONCLUSION: Varying the speed of injection of Propofol during induction of anesthesia in adult female patients does not cause any major difference in the drop of their heart rate, systolic blood pressure, diastolic pressure and mean arterial pressure.

Ocular phenylephrine 2.5% continues to be dangerous.

Phenylephrine 10% is used for pupillary dilatation and capillary decongestion. It had been advised to use a 2.5% concentration instead of 10% to guard against systemic reactions. Here, a case of severe systemic manifestation following conjuctival application of 2.5% phenylephrine is described.A healthy adult was admitted for pterygium excision under ophthalmic blockade. Vital signs remained normal until a sponge soaked with phenylephrine 2.5% was applied over the excised pterygium to control bleeding. The patient developed bradycardia (heart rate of 30 bpm) and hypotension (pressure 80/40 mmHg), so intravenous atropine was given. This was followed by tachycardia (heart rate of 150 bpm) and hypertension (pressure 240/130 mmHg) and ECG showed ischaemic changes. Treatment included propofol, labetalol, frusamide, morphine and dexamethasone. The next day, a 12-lead ECG showed no ischaemic changes and the myocardial infarction screen was negative. Fundus examination showed no sign of papilloedema. This report emphasises that phenylephrine 2.5% is still dangerous, with unpredictable response.