- Email: [email protected]
358: Contralateral amaurosis and extraocular muscle palsies after retrobulbar injection
182
Posters
•
Miscellaneous
344. Safety and effficacy of intravenous fentanyl patient control analgesia (PCA) for intractable pain
358. Contralateral amaurosis and extraocular muscle palsies after retrobulbar injection
M. Karanikolas1, D. Aretha1, G. Monantera1, I. Tsolakis2, P. Kiekkas1, S. Papadoulas2, K.S Filos1 1Aneshesiology and Critical Care, University Hospital of Patras, Patras, Rion, Greece, 2Department of Surgery, University Hospital of Patras, Patras, Rion, Greece
J. Sa´nchez Guijo, A. Diaz Martinez, F. Gonzalez Ruiz de la Herran, G. Perez Villarejo, A. Fernandez Valderrama Hospital Regional Universitario Carlos Haya, Ma´laga, Spain
Introduction: Intractable ischemic, neuropathic pain can be inadequately controlled despite state-of-the-art care. We present our experience from use of IV Fentanyl PCA for limb pain in 20 patients (16 men and 4 women), all of which were scheduled for amputation.
Background and Aims: To report a very rare complication of retrobulbar anaesthesia in ophthalmic surgery: amaurosis and extraocular muscle palsies in the contralateral eye. We explain the mechanism of this II,III cranial nerves block and how to avoid it.
Methods: Fentanyl was administered via an Abbott Corporation pump (initial settings: 25 mcg bolus, 20 minutes lockout, no basal infusion). The PCA titrated to Visual Analogue Scale (VAS) score at 4 or less, offered approximately 48 hours preamputation and continued for approximately 48 more hours postamputation. Pain was assessed twice daily with a VAS score. The McGill pain questionnaire (MPQ) ⫺ total ranked rating index (PRI(R)), was administered twice (before and 24 hours after PCA started). Sedation was assessed twice daily on a four-point likert scale: 1) agitated, 2) awake, 3) roused by voice and 4) unarousable. Pain scores were compared using a paired t-test (P-value ⬍0.05 significant). Data are presented as mean ⫾ SD. Results: The mean age was 67 ⫾ 9.63 years, the mean fentanyl dose was 30 ⫾ 12.4 mcg/h and the mean PCA duration was 102 ⫾ 28. Mean VAS and PRI(R) pain scores before PCA started was 8.9 ⫾ 1.35 and 31 ⫾ 11.29 respectively. After PCA started, mean VAS pain score decreased to 2.2 ⫾ 1.54 and mean PRI(R) score to 6.8 ⫾ 5.7. Overall, the reduction in VAS and PRI(R) scores were 73.8% (P⬍0.001) and 77.56 % (P⬍0.001) respectively. Sedation score was 2 in 18 patients and 3 in 2 female patients. There were no cases of respiratory depression. Discussion: IV Fentanyl PCA is effective and safe in providing relief in patients with ischemic-neuropathic pain which is a significant accomplishment, as this pain can be difficult to treat, and accumulation of opioids, resulting in toxicity, is an ever-present thought.
Methods: We carried out retrobulbar block in two patients undergoing cataracts surgery. A mixture of 2,5 mL bupivacaine 0.75% and 2,5 mL Lidocaine 2% was injected and Honan balloon was applied. Results: After surgery patients had a bilateral amaurosis and also a bilateral cranial III nerve block (Figure 1). Visual acuity as well as extraocular muscle movement returned to normality in 60min. Conclusions: Numerous complications resulting from retrobulbar injections have been reported. The optic nerve has a complete dural cuff all the way to the sclera, and injection into this cuff leads to subarachnoid spread of the agent into the central nervous system. We propose that the inadvertent injection of anesthetic in the subdural or subarachnoid space can produce a cranial III nerve contralateral block. Contralateral blindness can be caused by reflux of the drug to the optic chiasm and then to the contralateral optic nerve. A technique in which patients look straight ahead avoids injection into the subarachnoid space. Injection should be performed without pain and not against resistance.
Posters
•
Miscellaneous
344. Safety and effficacy of intravenous fentanyl patient control analgesia (PCA) for intractable pain
358. Contralateral amaurosis and extraocular muscle palsies after retrobulbar injection
M. Karanikolas1, D. Aretha1, G. Monantera1, I. Tsolakis2, P. Kiekkas1, S. Papadoulas2, K.S Filos1 1Aneshesiology and Critical Care, University Hospital of Patras, Patras, Rion, Greece, 2Department of Surgery, University Hospital of Patras, Patras, Rion, Greece
J. Sa´nchez Guijo, A. Diaz Martinez, F. Gonzalez Ruiz de la Herran, G. Perez Villarejo, A. Fernandez Valderrama Hospital Regional Universitario Carlos Haya, Ma´laga, Spain
Introduction: Intractable ischemic, neuropathic pain can be inadequately controlled despite state-of-the-art care. We present our experience from use of IV Fentanyl PCA for limb pain in 20 patients (16 men and 4 women), all of which were scheduled for amputation.
Background and Aims: To report a very rare complication of retrobulbar anaesthesia in ophthalmic surgery: amaurosis and extraocular muscle palsies in the contralateral eye. We explain the mechanism of this II,III cranial nerves block and how to avoid it.
Methods: Fentanyl was administered via an Abbott Corporation pump (initial settings: 25 mcg bolus, 20 minutes lockout, no basal infusion). The PCA titrated to Visual Analogue Scale (VAS) score at 4 or less, offered approximately 48 hours preamputation and continued for approximately 48 more hours postamputation. Pain was assessed twice daily with a VAS score. The McGill pain questionnaire (MPQ) ⫺ total ranked rating index (PRI(R)), was administered twice (before and 24 hours after PCA started). Sedation was assessed twice daily on a four-point likert scale: 1) agitated, 2) awake, 3) roused by voice and 4) unarousable. Pain scores were compared using a paired t-test (P-value ⬍0.05 significant). Data are presented as mean ⫾ SD. Results: The mean age was 67 ⫾ 9.63 years, the mean fentanyl dose was 30 ⫾ 12.4 mcg/h and the mean PCA duration was 102 ⫾ 28. Mean VAS and PRI(R) pain scores before PCA started was 8.9 ⫾ 1.35 and 31 ⫾ 11.29 respectively. After PCA started, mean VAS pain score decreased to 2.2 ⫾ 1.54 and mean PRI(R) score to 6.8 ⫾ 5.7. Overall, the reduction in VAS and PRI(R) scores were 73.8% (P⬍0.001) and 77.56 % (P⬍0.001) respectively. Sedation score was 2 in 18 patients and 3 in 2 female patients. There were no cases of respiratory depression. Discussion: IV Fentanyl PCA is effective and safe in providing relief in patients with ischemic-neuropathic pain which is a significant accomplishment, as this pain can be difficult to treat, and accumulation of opioids, resulting in toxicity, is an ever-present thought.
Methods: We carried out retrobulbar block in two patients undergoing cataracts surgery. A mixture of 2,5 mL bupivacaine 0.75% and 2,5 mL Lidocaine 2% was injected and Honan balloon was applied. Results: After surgery patients had a bilateral amaurosis and also a bilateral cranial III nerve block (Figure 1). Visual acuity as well as extraocular muscle movement returned to normality in 60min. Conclusions: Numerous complications resulting from retrobulbar injections have been reported. The optic nerve has a complete dural cuff all the way to the sclera, and injection into this cuff leads to subarachnoid spread of the agent into the central nervous system. We propose that the inadvertent injection of anesthetic in the subdural or subarachnoid space can produce a cranial III nerve contralateral block. Contralateral blindness can be caused by reflux of the drug to the optic chiasm and then to the contralateral optic nerve. A technique in which patients look straight ahead avoids injection into the subarachnoid space. Injection should be performed without pain and not against resistance.