Surgical outcomes of macular hole and epimacular membrane treatment in patients with intraoperative amaurosis under sub-Tenon's anesthesia.

OBJECTIVE: Some patients have been found to develop intraoperative amaurosis under sub-Tenon's anesthesia. We explored whether these patients have poor surgical outcomes during mid- to long-term postoperative follow-up. METHODS: In this case series, 74 of 85 patients with macular diseases who underwent phacoemulsification combined with vitrectomy under sub-Tenon's anesthesia developed intraoperative amaurosis. The surgical outcomes at the 2- and 4-month follow-ups in these patients were investigated and compared with the outcomes in patients without amaurosis using best-corrected visual acuity (BCVA), optical coherence tomography (OCT), and pattern visual evoked potential (PVEP). RESULTS: Both BCVA and the OCT-based macular structure in patients with intraoperative amaurosis showed significant postoperative improvement comparable with that of patients without amaurosis. The presence of intraoperative amaurosis was not associated with either macular hole closure or macular edema regression. PVEP revealed no significant changes in the wave latency or amplitude before and after surgery. CONCLUSION: Intraoperative amaurosis following sub-Tenon's block is commonly seen but does not predict a poor surgical prognosis. When a patient develops amaurosis during surgery, the surgeon should increase patient comfort through verbal communication rather than perform an additional intervention to help relieve the patient's anxiety.

The Nerve to Thyrohyoid Muscle as a Novel Donor Nerve for Laryngeal Reinnervation.

OBJECTIVES: Recurrent laryngeal nerve (RLN) injury may be a consequence of surgical procedures of the skull base, neck, and chest, with adverse consequences to function and quality of life. Laryngeal reinnervation offers a potentially stable improvement in vocal fold position and tone. The classic donor nerve is the ansa cervicalis, but is not always available due to damage or sacrifice during previous neck surgeries. Our objective was to introduce the nerve to the thyrohyoid (TH) muscle as an alternate donor nerve for reinnervation, which has not previously been described. METHODS: Case series of two patients using the TH nerve for laryngeal reinnervation after RLN injury, with description of surgical harvest. RESULTS: Follow-up results are available for 10 months (one patient) and 3 years (one patient) demonstrating both subjective and objective improvement in function. GRBAS scores were reduced. Maximal phonation time was improved. Patient rating of voice was stable or improved postoperatively. One patient described significant preoperative dyspnea which was significantly improved postoperatively, from a score of 24 to 10 out of 40 on the dyspnea handicap index. VHI was improved in one patient, but scores elevated in the other, despite a change from "moderately severe impairment" to "normal voice" subjectively. Neither patient experienced significant complications from the procedure. CONCLUSION: Laryngeal reinnervation procedures provide good outcomes in pediatric patients. When ansa cervicalis is not available as a donor nerve, the nerve to TH provides a reasonable alternative.

Conversion of local anesthesia-guided deep brain stimulation of the subthalamic nucleus to general anesthesia.

BACKGROUND: Deep brain stimulation of the subthalamic nucleus (STN) is a widely applied procedure in the treatment of patients with advanced Parkinson disease and is generally performed under local anesthesia. Here we report our experience with the conversion to general anesthesia in two patients with advanced Parkinson disease because of fear reactions intraoperatively. CASE DESCRIPTION: Patients received general anesthesia with propofol and were implanted with electrodes at the level of STN guided by multiple-microelectrode electrophysiological recordings after obtaining informed consent. During the recordings the propofol levels were reduced. Postoperative clinical assessments showed marked improvements of motor disability with significant reductions of dopaminergic medication. CONCLUSION: Our case observations document the possibility of fear reactions intraoperatively and show the possibility of conversion to general anesthesia with a successful outcome.

Stress management training for surgeons-a randomized, controlled, intervention study.

BACKGROUND: Stress and coping influence performance. In this study, we evaluate a novel stress management intervention for surgeons. METHODS: A randomized control group design was used. Sixteen surgeons were allocated to either the intervention or control group. The intervention group received training on coping strategies, mental rehearsal, and relaxation. Performance measures were obtained during simulated operations and included objective-structured assessment of technical skill, observational teamwork assessment for surgery, and end product assessment rated by experts. Stress was assessed using the state-trait-anxiety-inventory, observer rating, coefficient of heart rate variability (C_HRV), and salivary cortisol. The number of applied surgical coping strategies (number of coping strategies [NC]) was assessed using a questionnaire. A t test for paired samples investigated any within-subject changes, and multiple linear regression analysis explored between-subject effects. Interviews explored surgeons' perceptions of the intervention. RESULTS: The intervention group showed enhanced observational teamwork assessment for surgery performance (t = -2.767, P < 0.05), and increased coping skills (t = -4.690, P < 0.01), and reduced stress reflected inheart rate variability (t = -4.008, P < 0.01). No significant changes were identified in the control group. Linear regression analysis confirmed a significant effect on NC (ß = -0.739, P < 0.01). Qualitative data analysis revealed improved technical skills, decision making, and confidence. CONCLUSIONS: The intervention had beneficial effects on coping, stress, and nontechnical skills during simulated surgery.

Analgesic effect of supplemental intracameral lidocaine during phacoemulsification under topical anaesthesia: a randomised controlled trial.

AIMS: To determine the analgesic effect of supplemental intracameral lidocaine 1% during phacoemulsification under topical anaesthesia, and to assess the risk factors associated with pain. METHODS: In a double-masked, randomised, clinical trial, 506 patients undergoing phacoemulsification under topical anaesthesia were randomised to receive a supplemental intracameral injection of either 0.5 cc of 1% lidocaine (277 patients, 54.7%) or balanced salt solution (BSS) (229 patients, 45.3%). Patients were interviewed by a trained interviewer using a standardised questionnaire. The main outcome measure was intraoperative pain, scored on a visual analogue scale of 0-10. Logistic regression was performed to assess ORs. RESULTS: 125 of 277 patients (45.1%) experienced pain in the lidocaine group, compared with 123 of 229 patients (53.7%) in the BSS group. The proportion of patients who experienced pain was significantly lower in the intracameral lidocaine group compared with the BSS group (multivariate OR 0.68, 95% CI 0.47 to 0.97; p=0.034). The median pain score (range) was 0.0 for intracameral lidocaine group compared with 1.0 for BSS group (p=0.039). Pain was more common in females (54.3% vs 43.6%; OR 1.56), non-Chinese (62.3% vs 46.9%; OR 2.13) and those who had previous cataract surgery to the fellow eye (55.3% vs 44.7%; OR 1.61). CONCLUSION: The use of 0.5 cc of 1% intracameral lidocaine during phacoemulsification under topical anaesthesia significantly reduces pain experienced by patients. Risk factors for pain include females, non-Chinese and previous cataract surgery.

Anaesthesia for phacosemulsification surgery: is it as comfortable as we think?

We report an observational prospective study to determine which local anaesthetic technique gave the most comfort during phacoemulsification (cataract) surgery. 1835 patients were recruited. 61.8% were female. Peribulbar (18.2%), subtenons (28.6%), and topical (53.2%) anaesthesia was used. The pain score was assessed by the visual analogue pain scale (VAPS) which ranged from 0 (no pain) to 10 (worse possible pain). The lowest mean pain score occurred in the subtenons group, mean VAPS 0.2 (95% CI 0.1-0.3). The mean pain scores for topical and peribulbar anaesthesia were 0.6 (95% CI 0.5-0.7) and 0.59 (95% CI 0.41-0.76) respectively. Subtenons anaesthesia gave the most comfort during phacoemulsification. Patients experienced more discomfort with 2nd eye surgery. Older patients and males had a higher pain threshold in all three anaesthetic groups.

Patient perceptions of "awake" brain tumour surgery.

BACKGROUND: Awake brain tumour surgery allows intraoperative patient assessment and is done to optimise safe tumour removal. It is an established technique but little is known about patient perceptions of the procedure. METHOD: Fifteen adult patients filled out a dedicated questionnaire to assess 10 aspects of patient perceptions of the procedure. FINDINGS: All patients, who were awake for a median of 45 minutes (range 10-105), stated they were adequately prepared for the operation. Most recollected various aspects of the procedure, although 3 patients (20%) had little memory of actually being awake during the surgery despite being cooperative. A minority reported more than minor discomfort (20%), fear (15%) or anxiety (29%), and most felt they coped with the cortical stimulations and functional testing well. Sources of discomfort and pain were the cranial pin holding device, operative position, inadequate infiltration of the cranial wound with local anesthetic, a full bladder causing a desire to micturate and a hard and uncomfortable operating table. CONCLUSIONS: These results, are very similar to a previous American report using a different anesthetic technique, in that most patients tolerate awake craniotomy remarkably well if the procedure is explained to them and some simple precautions are taken. Additionally between 8%-37% of patients (95% Confidence Interval, summing data from the two studies, n = 35) will have no recollection of being awake. Ways of minimising discomfort and problems of anxiety in this patient cohort are discussed.

The effects of handholding on anxiety in cataract surgery patients under local anaesthesia.

AIM OF THE STUDY: To assess the effectiveness of handholding on the anxiety of patients undergoing planned cataract surgery under local anaesthesia. BACKGROUND: Anxiety concerning anaesthesia, pain, physical injuries, isolation, prognosis, possibilities of deformity, or loss of self-control may be stressful to patients undergoing surgery. Anxiety activates the sympathetic nervous system, characterized by an increase in catecholamine concentration, heart rate and blood pressure and increased glucocorticoid levels; it also affects immune responses. Therefore, there is a need for nursing interventions to reduce the anxiety of patients under local anaesthesia who are conscious. METHODS: An untreated control group design with pre and post-test was used. Among 62 patients, 30 were randomly assigned to the handholding group and 32 to the control group. Handholding was provided to subjects of the handholding group during surgery. Visual analogue scales and interviews were used to measure anxiety, and pulse rate and systolic and diastolic blood pressure were used as physiological measures of stress. Blood was taken for analysis of levels of epinephrine, norepinephrine, cortisol, neutrophils, lymphocytes and natural killer cells. RESULTS: The number of subjects who reported decreased anxiety during operation was significantly higher in the handholding group compared with the control group and most of the subjects reported that handholding during operation was very helpful in reducing anxiety. Epinephrine levels in the handholding group were significantly lower than in the control group. CONCLUSIONS: Results suggest that this noninvasive intervention has potential for reducing anxiety in patients having cataract surgery under local anaesthesia.

[Perioperative anxiety and postoperative pain suppression in intraocular operations using general anesthesia and local anesthesia]. / Perioperatives Angsterleben und postoperatives Schmerzverhalten bei intraokulären Eingriffen in Allgemeinanaesthesie und Lokalanaesthesie.

UNLABELLED: Intraocular surgery is performed under local or general anesthesia. The indications for these procedures are often dependent on local circumstances. On the one hand, the optimal conditions for operations under general anesthesia, on the other, the negligible stress of local anesthesia, especially for the elderly, are emphasized. To clarify this question, perioperative anxiety behavior and postoperative pain were investigated in geriatric patients undergoing ophthalmic surgery. METHODS: Spielberger's state trait anxiety inventory (STAI) was performed in 31 patients operated on in general (age 71.0 +/- 6.6 SEM) and 31 operated on in local anesthesia (age 71.6 +/- 6.0 SEM) the day before and 4 h after operation. 10 patients in each group were also tested immediately before surgery in the operating room. Postoperative pain was estimated by the patient and postoperative sedation by the investigator using a 4-point scale for each over 8 h. RESULTS: The state (STAI 1) and trait (STAI 2) anxiety scores did not change in these geriatric patients. There were no significant differences between the groups. Postoperative pain was significantly (p less than 0.05) higher after 15 and 60 min after general anesthesia. There was no difference in the frequency of analgetic therapy in both groups, but most opioids were given in the first 90 min after general anesthesia. The patients were more frequently sedated (p less than 0.05) in the first 90 min after general anesthesia then after local anesthesia. DISCUSSION: The scores of state and trait anxiety behavior are comparable to a normal geriatric population, even if normal data cannot always be applied to clinical situations.(ABSTRACT TRUNCATED AT 250 WORDS)