Stellate ganglion block and cardiac sympathetic denervation in patients with inappropriate sinus tachycardia.

BACKGROUND: Inappropriate sinus tachycardia (IST) remains a clinical challenge because patients often are highly symptomatic and not responsive to medical therapy. OBJECTIVE: To study the safety and efficacy of stellate ganglion (SG) block and cardiac sympathetic denervation (CSD) in patients with IST. METHODS: Twelve consecutive patients who had drug-refractory IST (10 women) were studied. According to a prospectively initiated protocol, five patients underwent an electrophysiologic study before and after SG block (electrophysiology study group). The subsequent seven patients had ambulatory Holter monitoring before and after SG block (ambulatory group). All patients underwent SG block on the right side first, and then on the left side. Selected patients who had heart rate reduction ≥15 beats per minute (bpm) were recommended to consider CSD. RESULTS: The mean (SD) baseline heart rate (HR) was 106 (21) bpm. The HR significantly decreased to 93 (20) bpm (P = .02) at 10 minutes after right SG block and remained significantly slower at 97(19) bpm at 60 minutes. Left SG block reduced HR from 99 (21) to 87(16) bpm (P = .02) at 60 minutes. SG block had no significant effect on blood pressure or HR response to isoproterenol or exercise (all P > .05). Five patients underwent right (n = 4) or bilateral (n = 1) CSD. The clinical outcomes were heterogeneous: one patient had complete and two had partial symptomatic relief, and two did not have improvement. CONCLUSION: SG blockade modestly reduces resting HR but has no significant effect on HR during exercise. Permanent CSD may have a modest role in alleviating symptoms in selected patients with IST.

Incidence and impact factors of intraoperative loss of light perception under sub-Tenon's anesthesia in patients with macular diseases.

PURPOSE: To investigate the incidence and impact factors of intraoperative loss of light perception (LP) under sub-Tenon's anesthesia in patients with macular diseases. METHODS: Eighty-five consecutive patients received standard phacoemulsification combined pars plana vitrectomy (PPV) under sub-Tenon's anesthesia. At several checkpoints during the surgery (the end of phacoemulsification, the end of vitrectomy, and the end of surgery), participants were interviewed about whether they had LP or not after removing the influence of contralateral eye and the photo-bleaching effect. In patients treated with retinal photocoagulation, visual experience on laser flashes was evaluated. RESULTS: Under routine draping, no patients reported loss of LP at all the checkpoints. When the contralateral eye was tightly covered, the rates of LP loss were 84.7%, 97.6%, and 87.1% at the end of phacoemulsification, the end of vitrectomy, and the end of surgery, respectively. When the photo-bleaching effect was also removed, the rates of LP loss were 61.2%, 82.4%, and 56.5% at each checkpoint, respectively, and there were 87.1% (74/85) of patients reporting visual loss in at least one checkpoint. In addition, 76.9% (50/65) of patients could not feel laser flashes during retinal photocoagulation. CONCLUSION: Intraoperative loss of LP under sub-Tenon's anesthesia was a relatively common and reversible event. The conduction block of optic nerve by anesthetic mainly contributed to the visual loss during surgery. Photo-bleaching effect also has some effect on the LP evaluation. Surgeons need to inform and counsel the patients about the intraoperative loss of LP, to prevent any sudden panic attacks in them.

Prospective evaluation of anesthetic protocols during pediatric ophthalmic surgery.

PURPOSE: To date, no protocol of anesthesia for pediatric ophthalmic surgery is unanimously recognized. The primary anesthetic risks are associated with strabismus surgery, including oculocardiac reflex, postoperative nausea and vomiting, and postoperative pain. METHODS: This was a prospective, monocentric, observational study conducted in a tertiary pediatric ophthalmic unit. Our anesthetic protocol for strabismus surgery included postoperative nausea and vomiting prevention using dexamethasone and ondansetron. No drug-based prevention of oculocardiac reflex or local/locoregional anesthesia was employed. RESULTS: A total of 106 pediatric ophthalmic surgeries completed between November 2015 and May 2016 were analyzed. The mean patient age was 4.4 (range: 0.2-7.3, standard deviation: 2.4) years. Ambulatory rate was 90%. Oculocardiac reflex incidence was 65% during strabismus surgery (34/52), 50% during congenital cataract surgery (4/8), 33% during intramuscular injection of botulinum toxin (1/3), and 0% during other procedures. No asystole occurred. Postoperative nausea and vomiting incidence was 9.6% after strabismus surgery (5/52) and 0% following the other procedures. One child was hospitalized for one night because of persistent postoperative nausea and vomiting. Postoperative pain generally occurred early on in the recovery room and was quickly controlled. Its incidence was higher in patients who underwent strabismus surgery (27%) than in those who underwent other procedures (9%). CONCLUSION: Morbidity associated with ophthalmic pediatric surgery is low and predominantly associated with strabismus surgery. The benefit-risk ratio and cost-effectiveness of oculocardiac reflex prevention should be questioned. Our postoperative nausea and vomiting rate is low, thanks to the use of a well-managed multimodal strategy. Early postoperative pain is usually well-treated but could probably be more effectively prevented.

Large exotropia after retrobulbar anesthesia.

A 67-year-old woman complained of horizontal diplopia shortly following bilateral cataract surgery with intraocular lens implantation performed under retrobulbar anesthesia. Retrobulbar anesthesia was administered at an inferotemporal injection site using 1 cc lidocaine hydrochloride 2% mixed with bupivacaine hydrochloride 0.5%. The initial ophthalmologic evaluation showed a 12-prism diopter (PD) exotropia, and ocular motility evaluation revealed marked limitation of adduction without vertical limitation. One year after cataract surgery, the exodeviation increased up to 60 PD. The patient underwent an 8.0-mm recession of the right lateral rectus and a 6.0-mm recession of the left lateral rectus. Both lateral rectus muscles were biopsied, and biopsy revealed dense fibrous connective tissue without viable muscular cells. The lateral rectus muscle might be injured by retrobulbar anesthesia, and it could induce large exotropia.

Topical lidocaine enhanced by laser pretreatment: a safe and effective method of analgesia for facial rejuvenation.

BACKGROUND: Injectable forms of anesthesia for nonsurgical facial rejuvenation, although efficacious, are uncomfortable for the patient. Preclinical studies have demonstrated that laser pretreatment at low energies enhances absorption of topical lidocaine. OBJECTIVES: The authors assess the safety and efficacy of laser-assisted transdermal delivery of topical anesthetic. METHOD: Ten patients were split into 2 groups (A and B). All patients received 15 g of BLT (20% benzocaine, 6% lidocaine, and 4% tetracaine triple anesthetic cream) for 20 minutes with no occlusion. Then the cream was removed and the first blood draw taken. Group A patients were pretreated with the full ablative laser and group B patients with a fractional ablative laser to the full face. A further 15 g BLT was applied for another 20 minutes. Group A patients then underwent full ablative laser treatment, and group B received fractionated ablative laser treatment. Blood draws were taken at 60, 90, 120, 180, and 240 minutes after the initial topical anesthetic application, and the serum was analyzed for lidocaine and monoethylglycinexylidide (MEGX) levels. Patients were asked to rate the pain felt at intervals during the procedure. RESULTS: No patient required supplemental nerve blocks. Pain scores were equivalent at the end of the first pass for both groups (P = .436). Group A patients had significantly lower pain scores at the start of the second laser treatment (P = .045), but pain scores became equivalent by the end (P = .323). Combined serum lidocaine and MEGX levels were significantly higher in group A patients up to 90 minutes (peak average of 0.61 µg/mL for group A and 0.533 µg/mL for group B; P = .0253), which corresponded to greater initial analgesic effect. CONCLUSIONS: Data from this study demonstrate that topical anesthetic for facial rejuvenation can be enhanced with laser pretreatment while maintaining safe blood serum levels. Further studies should examine optimal application amount and time to allow safe multipass facial rejuvenation without the need for invasive nerve blocks.

Combined topical and intracameral anesthesia for Descemet's stripping automated endothelial keratoplasty.

To evaluate the use of combined topical and intracameral anesthesia for Descemet's stripping automated keratoplasty (DSAEK). This was a retrospective comparative cohort analysis consisting of 10 eyes in 10 consecutive patients undergoing DSAEK surgery with combined topical and intracameral anesthesia. These cases were compared with 21 randomly selected controls during the same time period undergoing DSAEK surgery performed under retrobulbar anesthesia. Incidence of intraoperative and postoperative complications, and endothelial cell counts were compared. In all cases, DSAEK was completed without intraoperative complications. All patients tolerated the procedure well. There were 6 cases of postoperative graft dislocation requiring rebubbling, and no cases of primary failure or endophthalmitis. No significant difference in endothelial cell counts was found at final follow-up. Short-term results suggest that combined topical and intracameral anesthesia is as safe and effective for DSAEK in cooperative patients when compared to retrobulbar anesthesia. It may thereby be an alternative anesthetic modality for patients in whom retrobulbar or peribulbar anesthesia may be risky or contraindicated.

Two-quadrant high-volume sub-Tenon's anaesthesia for vitrectomy: a randomised controlled trial.

BACKGROUND: Total volume using a standard single inferonasal injection for sub-Tenon's anaesthesia is limited by an increase in intraocular pressure (IOP) and commonly requires the operating surgeon to top-up the block intraoperatively. This study compares the efficacy and safety of a two-quadrant technique that allows the use of a higher volume of local anaesthetic. METHODS: 54 patients undergoing vitrectomy were randomised into two groups. The control group (n=27) received a standard 5 ml single inferonasal sub-Tenon injection of a 50:50 mixture of 2% lidocaine and 0.5% bupivacaine with 150 IU hyaluronidase. The study group (n=27) received a 5 ml inferonasal and 5 ml superotemporal injection of the same mixture (10 ml total). The primary outcome measure was the number of intraoperative top-ups required. Secondary outcome measures were intraoperative and postoperative pain scores, IOP, block onset time, ocular akinesia, eyelid akinesia and chemosis. RESULTS: 24 patients required a top-up in the control group. No patients required a top-up in the study group (p<0.001). IOP measurements were similar in both groups. Block onset was shorter, eyelid akinesia was improved and pain scores were also reduced in the study group intraoperatively and at 0-2 h, 4-6 h, 10-14 h and 20-24 h postoperatively. CONCLUSIONS: Two-quadrant sub-Tenon's anaesthesia using 10 ml of a 50:50 mixture of 2% lidocaine and 0.5% bupivacaine with 150 IU hyaluronidase seems to be more effective than a single-quadrant technique at reducing intraoperative and postoperative pain during vitrectomy.

Inadvertent intracorneal injection of local anesthetic during lid surgery.

PURPOSE: To report a case of inadvertent intracorneal injection of anesthetic agents during lid anesthesia and corneal penetration without full-thickness perforation. METHOD: Case report. RESULTS: Corneal edema with acute loss of vision was noted. The patient was treated with topical, antibiotic, cycloplegic, hyperosmotic agent and lubricant. While the edema slowly subsided, a loss in endothelial cell count was noted. CONCLUSIONS: The effects of intracorneal injection of lignocaine, bupivacaine, and its preservatives have not previously been reported in the literature. A lower postinjection endothelial cell count and associated clinical features in our case indicate that endothelial toxicity occurred. This potential complication should be kept in mind with necessary precautions taken during injection of the eyelid, particularly in cases with preexisting lid laxity.

Comparison of 4% articaine and 0.5% levobupivacaine/2% lidocaine mixture for sub-Tenon's anaesthesia in phacoemulsification cataract surgery: a randomised controlled trial.

BACKGROUND/AIMS: [corrected] The aim of this study was to compare the efficacy and safety of 4% articaine with a mixture containing equal volumes of 2% lidocaine and 0.5% levobupivacaine without hyaluronidase for sub-Tenon's anaesthesia in phacoemulsification cataract surgery. METHODS: The study was a prospective, randomised double-masked clinical trial of 65 patients allocated to receive either 4% articaine or a mixture containing equal parts of 2% lidocaine and 0.5% levobupivacaine. All patients had pre- and postoperative Hess charting to document ocular motility dysfunction. Ocular and eyelid movements were scored at 2 min intervals from 2 to 10 min after injection of the anaesthetic agent, and at the end of surgery. Complications related to injection, including pain, chemosis and subconjunctival haemorrhage, were recorded. Patients rated pain (none/mild/moderate/severe) during surgery. The operating surgeon masked to the anaesthetic agent assessed proptosis/chemosis at the start of the operation and the degree of ocular akinesia and analgesia at the end of surgery. RESULTS: The articaine group demonstrated a rapid onset of ocular akinesia with a mean time to readiness for surgery (achieving a score of

The use of compound topical anesthetics: a review.

BACKGROUND: The author reviewed the history of, federal regulations regarding, risks of and adverse drug reactions of five compound topical anesthetics: tetracaine, adrenaline/epinephrine and cocaine (TAC); lidocaine, adrenaline/epinephrine and tetracaine (LET); lidocaine, tetracaine and phenylephrine (TAC 20 percent Alternate); lidocaine, prilocaine and tetracaine (Profound); and lidocaine, prilocaine, tetracaine and phenylephrine with thickeners (Profound PET). TYPES OF STUDIES REVIEWED: The author reviewed clinical trials, case reports, descriptive articles, and U.S. Food and Drug Administration (FDA) regulations and recent public advisory warnings regarding the federal approval of and risks associated with the use of compound topical anesthetics. RESULTS: Compound topical anesthetics are neither FDA-regulated nor -unregulated. Some compounding pharmacies bypass the new FDA drug approval process, which is based on reliable scientific data and ensures that a marketed drug is safe, effective, properly manufactured and accurately labeled. Two deaths have been attributed to the lay use of compound topical anesthetics. In response, the FDA has announced the strengthening of its efforts against unapproved drug products. CLINICAL IMPLICATIONS: Compound topical anesthetics may be an effective alternative to local infiltration for some minimally invasive dental procedures; however, legitimate concerns exist in regard to their safety. Until they become federally regulated, compound topical anesthetics remain unapproved drug products whose benefits may not outweigh their risks for dental patients.

Frequency of transient ipsilateral vocal cord paralysis in patients undergoing carotid endarterectomy under local anesthesia.

BACKGROUND: Especially because of improvements in clinical neurologic monitoring, carotid endarterectomy done under local anesthesia has become the technique of choice in several centers. Temporary ipsilateral vocal nerve palsies due to local anesthetics have been described, however. Such complications are most important in situations where there is a pre-existing contralateral paralysis. We therefore examined the effect of local anesthesia on vocal cord function to better understand its possible consequences. METHODS: This prospective study included 28 patients undergoing carotid endarterectomy under local anesthesia. Vocal cord function was evaluated before, during, and after surgery (postoperative day 1) using flexible laryngoscopy. Anesthesia was performed by injecting 20 to 40 mL of a mixture of long-acting (ropivacaine) and short-acting (prilocaine) anesthetic. RESULTS: All patients had normal vocal cord function preoperatively. Twelve patients (43%) were found to have intraoperative ipsilateral vocal cord paralysis. It resolved in all cases < or =24 hours. There were no significant differences in operating time or volume or frequency of anesthetic administration in patients with temporary vocal cord paralysis compared with those without. CONCLUSION: Local anesthesia led to temporary ipsilateral vocal cord paralysis in almost half of these patients. Because pre-existing paralysis is of a relevant frequency (up to 3%), a preoperative evaluation of vocal cord function before carotid endarterectomy under local anesthesia is recommended to avoid intraoperative bilateral paralysis. In patients with preoperative contralateral vocal cord paralysis, surgery under general anesthesia should be considered.

Safety and efficacy of two ocular anesthetic methods for phacoemulsification: topical anesthesia and viscoanesthesia (VisThesia).

PURPOSE: VisThesia is a new ophthalmic viscosurgical device (OVD) which has 1% lidocaine combined with 1.5% sodium hyaluronate. This is a prospective evaluation of the safety and efficacy of VisThesia used in association with phacoemulsification. METHODS: A total of 114 eyes were divided into two groups. Fifty-nine eyes were treated with tetracaine + oxybuprocaine topical anesthesia and DuoVisc OVD and 55 eyes were treated with VisThesia, for use as both topical anesthetic and OVD. Endothelial cell counts were measured at 30 days postoperatively and compared to preoperative baseline values. Pain and discomfort was subjectively evaluated by patients using a visual analog pain scale (0-10). RESULTS: All surgeries were uneventful with no intraoperative or immediate postoperative complications. Patients receiving topical anesthesia had a mean pain score of 1.1+/-6.8 compared to a mean score of 1.3+/-4.6 for patients receiving VisThesia (p=0.59). Postoperatively, endothelial cell loss at 1 month was greater for patients receiving VisThesia (20.32%+/-43.75) than for those receiving the topical anesthetic (8.8%+/-59.6; p<0.0001). CONCLUSIONS: The results from the visual analog pain scale were comparable between groups, showing that VisThesia provides similar pain relief to topical anesthesia. Specular microscopy performed at 30 days postoperatively showed a significantly greater loss of endothelial cells with the use of VisThesia, suggesting that the 1% lidocaine concentration used in VisThesia may be toxic to corneal endothelial cells.

Safety of cataract surgery under topical anesthesia with oral sedation without anesthetic monitoring.

PURPOSE: The current study was conducted to determine whether topical anesthesia with oral sedation and without an anesthetist present in the operating room is a safe and cost-effective strategy for low-risk patients undergoing cataract surgery. METHODS: This retrospective interventional case series included cases conducted between 2001 and 2003 at the Brandon Regional Health Centre in Brandon, Manitoba. Patients with visually significant cataracts were screened for study inclusion by using the following criteria: good general health, good dilation, moderate cataracts, cooperation with in-office tests and procedures, and understanding of cataract surgery. Oral sedation was provided by lorazepam, and an anesthetist was available to manage any medical adverse events. Topical anesthesia was achieved by means of tetracaine drops, lidocaine hydrochloride jelly, and intracameral lidocaine hydrochloride, as necessary. Main outcome measures were heart rate, systolic and diastolic blood pressure, oxygen saturation, intraoperative complications, and medical adverse events necessitating anesthetist intervention. RESULTS: A total of 538 eyes of 373 patients were included in the cataract surgery case series. No medical adverse events were reported in 454 cases (84.4%); 84 patients (15.6%) experienced adverse events, classified as mild in 13.5%, moderate in 1.1%, and severe in 0.9% (5 cases). The most common adverse event was mild pain, experienced in 69 procedures (12.8%). Moderate pain, necessitating use of intracameral 1% lidocaine, occurred in 3 procedures (0.6%). INTERPRETATION: Topical anesthesia appears to be a safe alternative to injection anesthesia without many of the disadvantages of the latter and may be preferable in carefully selected patients.

Orbital inflammation after sub-Tenon's anesthesia.

Two cases of orbital swelling after sub-Tenon's anesthesia are reported. The first patient presented 3 days postoperatively with proptosis and conjunctival chemosis. Computed tomography showed nonspecific inflammation of the orbital soft tissue. Signs and symptoms resolved after systemic steroids. The second patient presented with similar signs and mild pain on the fourth postoperative day. Computed tomography showed a similar diffuse orbital inflammation. The patient was treated with oral steroids and antibiotics, and all inflammation subsided within 4 weeks. Both patients had uneventful cataract surgery, were apyrexial, and were generally well. A few possible mechanisms for these episodes are infection, reaction to povidone-iodine or sub-Tenon's anesthetic, or trauma due to the sub-Tenon's cannula.

Inferior oblique overaction/contracture following retrobulbar anesthesia for cataract extraction with a positive Bielschowsky Head Tilt test to the contralateral shoulder. A report of one case.

BACKGROUND AND PURPOSE: This is a report of a patient with diplopia, hypertropia, extorsion and a positive Bielschowsky Head Tilt Test following retrobulbar anesthesia, due to an inferior oblique muscle overaction-contracture. CASE REPORT: Oculomotor and sensorimotor examinations and ocular motility recordings and Bielschowsky Head Tilt Test demonstrated overaction characteristics overpowering the contracture characteristics of the involved inferior oblique muscle. RESULTS: Weakening of the overacting inferior oblique eliminated the vertical and torsional deviations and the forced head tilt difference upon tilting the head to either shoulder. It also normalized ocular motility and resulted in a symptom-free patient. CONCLUSION: Oblique muscle dysfunction with vertical and torsional deviations and a positive Bielschowsky Head Tilt Test can result from retrobulbar anesthesia.

Diagnostic anaesthesia of the equine lower limb: a comparison of lidocaine and lidocaine with epinephrine.

The anaesthetic potency, onset of action, duration of action, and side effects of lidocaine and lidocaine plus epinephrine for proximal metacarpal block of the lateral and medial palmar nerves were determined. Ten horses were used and legs were injected using a cross-over model with three test solutions: 1) solvent and lidocaine (2%) plus epinephrine (SLE); 2) solvent and lidocaine (2%) without epinephrine (SL); and 3) solvent only (S). The contra-lateral leg was injected with saline (placebo; P). In both the SL and SLE groups, the onset of anaesthesia occurred between 5 and 15 minutes after injection. In the SL group the effect was short-lived, lasting 60 minutes, with a maximum effect at 15 minutes. SLE induced long-lasting anaesthesia in most animals moderate or total anesthesia lasted 6 hours, and in two horses more than 9 hours. The maximum effect was achieved at 60 and 90 minutes. Swelling, the main side effect, was seen halfway between the injection site and the fetlock joint. Swelling on day 1 was minimal in the legs injected with P (105.3%) but was progressively greater with S (129%), SL (136%), and SLE (172%). On day 1 and day 2 the differences between SLE and SL, and between SLE and S were significant (P < 0.05). The difference between S and SL was not significant. On day 3, the swelling had subsided and differences were no longer significant.

Effect of intratesticular injection of xylazine/ketamine combination on canine castration.

This study was performed to compare the effect of intratesticular (IT) injection of xylazine/ketamine combination for canine castration with those of intramuscular (IM) or intravenous (IV) injection. Xylazine and ketamine was administered simultaneously via intratesticularly (IT group), intramuscularly (IM group) or intravenously (IV group) at doses of 2 and 10 mg/kg, respectively. Pain response at the time of injection, mean induction time, mean arousal time, mean walking time and cardiopulmonary function during anesthesia were monitored after the xylazine and ketamine administration. In IV and IM groups, heart rates were significantly decreased 30 and 45 min after xylazine and ketamine administration, respectively (p < 0.05). Respiratory rates were significantly decreased in the IV group (p < 0.05). In the IT group, there was no significant changes in heart and respiratory rates. The occurrence of cardiac arrhythmias was less severe in IT group compared with those in IM and IV groups. The route of administration did not affect rectal temperature. Mean induction time was significantly (p < 0.05) longer in IT group than in IM and IV groups. On the contrary, mean arousal time and mean walking time were shortened in IT group. Clinical signs related to pain response at the time of injection and vomiting were less observed in IT group than in IM group, and head shaking was less shown in IT group than in IM and IV groups during recovery period. These results indicated that intratesticular injection of xylazine/ketamine for castration has several advantages such as less inhibition of cardiopulmonary function and fast recovery from anesthesia without severe complications, and would be an effective anesthetic method for castration in small animal practice.