Transcript Case Report presented in European Society of Regional

A Case Report: Sub-Tenon’s versus General
Anaesthesia – A Direct Comparison of a New
Anaesthetic Approach for Corneal Graft Surgery
Dr. Birgitt Straub, Dr. Brendan O’Hare, Dr. William Power, Dr. Muhammad Mukhtar
Royal Victoria Eye and Ear Hospital, Dublin
Introduction
Sub-Tenon’s anaesthesia is potentially the optimal technique for anterior chamber ophthalmic procedures, notably cataract surgery. Keratoplasties are most commonly performed under
general anaesthesia or to a lesser extent under peribulbar block.
This is the first report of successful use of Sub-Tenon’s anaesthesia for corneal graft surgery in Ireland – a new area of application for this simple and low risk technique.
We present the case of an ASA 3, high risk patient with severe cardiac disease, on full anticoagulation and antiplatelet therapy who underwent bilateral keratoplasty and cataract
surgery within 6 months under general anaesthesia and sub-Tenon’s block.
Method
Results
Case Details
A 72 year old male patient presented for bilateral
keratoplasty and cataract surgery. In our institution
Keratoplasties are routinely performed under general
anaesthesia. Only recently sub-Tenon’s anaesthesia
has been introduced as an anaesthetic approach for
patients at high risk for GA or peribulbar block.
Intraoperative monitoring
Drugs received
Cardiovascular stability
Surgical conditions
Akinesia
Intraoperative pain
Intraoperative analgesia
Postoperative monitoring
Postoperative analgesia
Surgical time
Recovery time
Total perioperative time
Past medical history
•
Severe IHD
•
CABG 5 vessel graft in 1986, 2002
•
Moderate to severe mitral regurgitation
•
Moderate pulmonary regurgitation
•
Atrial fibrillation , HR 70/min
•
HTN
Sub-Tenon’s Block
General Anaesthesia
standard monitoring
Lignocaine, Bupivacaine
stable throughout
good
good
pain free
Lignocaine, Bupivacaine
direct transfer to ward
Paracetamol 1g iv for mild pain
65min
0 min
1h45min
minor: mild subconjunctival
haemorrhage, chemosis
standard + IABP monitoring
multiple drugs
Ephedrine, Phenylephrine
good
good
pain free
Paracetamol 1g iv Morphine 3mg iv
standard monitoring in recovery
Morphine 2mg iv
55min
40 min
2h 15min
potential risk of graft displacement 2nd to rise
in IOP with PONV, coughing, inability to lie flat
Criteria for Comparison
Complications
reduced exercise tolerance, dyspnoea on moderate
exertion
Drug History
•
•
•
Aspirin 75mg daily – Platelet count 102-118x109/l
Akinesia of medial rectus muscle
Warfarin - INR 2.5 -3.2
Akinesia of levator palpebrae muscle
Furosemide, Amiloride, Bisoprolol, Candesartan
Sub-Tenon’s Space
Left Eye Keratoplasty August 2010 under GA
•
Invasive blood pressure monitoring pre-induction
•
Gentle iv induction of general anaesthesia
•
Anaesthesia maintenance with O2/N2O/Sevoflurane
•
Titrated vasoactive drugs to maintain cardiovascular
stability
•
•
Ephedrine 18mg iv
•
Phenylephrine 600mg iv
Analgesia perioperatively
•
Morphine 5mg iv
•
Paracetamol 1g iv
Tenon’s Capsule
Akinesia of superior rectus muscle
Akinesia of lateral rectus muscle
Discussion
•
Sub- Tenon’s Block
- Requires cooperative patient
+ Simple, low risk eye block
Uneventful perioperative course
+ good analgesia, akinesia, patient comfort without
cardiac compromise
Right Eye Keratoplasty in March 2011 under SubTenon’s Block
+ No polypharmacy
+ shorter theatre times, no need for recovery
On presentation patient complained of worsened
dyspnoea on now mild exertion
•
Standard monitoring
•
Topicalisation of eye
•
Subtenon injection with 19G cannula
•
Lignocaine 2% 2ml+Bupivacaine 0.5% 2ml +
Hyaluronidase 37.5IU/ml
•
Mild discomfort on injection
•
Digital ocular pressure post injection x 3min
•
Good akinesia, excellent anaesthesia
•
Direct transfer to ward postoperatively
•
Paracetamol 1g iv for mild postoperative pain
Discharged on postoperative Day 2 on both occasions
Conclusion
+ avoids postoperative rises in IOP due to vomiting,
coughing, able to comply with postoperative
positioning
•
In experienced hands
Sub-Tenon’s Anaesthesia
is a safe and effective
technique suitable for
keratoplasties especially
in high risk patients
General Anaesthesia
+ Excellent akinesia, no time constraint
+ Reduced risk of haemorrhage under anticoagulation
-
high cardiac risk due to cardiovascular effects of
anaesthetic medication, surgical/anaesthetic stimulation
and positive pressure ventilation
- Risk of PONV, coughing, postoperative hypoxia,
postoperative pain
•
Peribulbar Block
- High risk block, contraindicated in clotting disorders
References:
1. A review of sub-Tenon’s block: current practice
and recent development C. M. Kumar, S. Williamson, B.
Manickam European Journal of Anaesthesiology 2005;
22: 567–577
2. Peribulbar anaesthesia during Keratoplasty: A
prospective study of 100 cases. Muraine M. etal
Br J Ophthalmol 1999;83: 104-109
3. A Case Report of Corneal Graft Surgery (Penetrating
Keratoplasty under Sub-Tenon’s Block H R M A Barker
and C M Moore, http://priory.com/anaes/subtenon.htm