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A complication of combined regional anesthesia techniques for ophthalmic surgery
ELSEVIER
A Complication of Combined Regional Anesthesia Techniques for Ophthalmic Surgery Annie Joseph, MD, FFARCS,* Thomas M. Fuhrman, MD, MMSc, FCCMt Department of Anesthesiology, University of South Florida College of Medicine, and Bay Pines Veterans’ Administration Medical Center, Bay Pines, Florida.
Keywords: Combined regional medical problems; ophthalmic
techniques; surgery.
multiple
Introduction Ophthalmic operations often are performed on elderly patients with significant medical problems. As a result, there may be relative contraindications to either general or regional anesthesia techniques. A patient with debilitating chronic lung disease presented for cataract extraction and intraocular lens implantation. The patient also had persistent leg and back pain that prevented him from remaining stationary for even a short period of time. It was felt that a regional block anesthesia with sedation would be hazardous. Therefore, a combination of peribulbar and lumbar epidural anesthesia was performed. This resulted in excellent patient and operating conditions. However, the patient’s intraocular pressure (IOP) increased, necessitating a delay in the operative procedure. Ultimately, the bladder distention was relieved, allowing IOP to decrease, and the operation was completed.
Case Report A 64year-old obese (107 kg, 180 cm) white male presented with a two-year history of a cataract of the left eye.
*Assistant Professor tAssociate Professor Address reprint requests to Dr. Joseph at the Department of Anesthesiology, University of South Florida College of Medicine, 12901 Bruce B. Downs Blvd., MDC 59, Tampa, Florida 33612. Received for publication February 14, 1995; revised manuscript cepted for publication May 16, 1995.
Journal of Clinical Anesthesia 8:248-250, 1996 0 1996 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
ac-
The patient’s medical history included coronary artery disease with two previous myocardial infarctions 10 years earlier, chronic obstructive lung disease, glaucoma, and generalized osteoporosis secondary to his continuous use of steroids to treat his pulmonary disease. He had been admitted to the hospital numerous times for exacerbations of his pulmonary disease. The last admission for this problem was two months prior to this operation. Although the patient denied angina, he had only minimal exercise tolerance. His pulmonary condition caused him to be chronically short of breath. He was unable to walk, ambulating only with the aid of a wheelchair due to relentless back, hip, and leg pain. This pain was so severe that he could not tolerate his previous ophthalmic procedure under a nerve block and required a general anesthetic intraoperatively. That operation was successful but was complicated by significant coughing on emergence and aggravation of his leg and back pain. In addition, his pulmonary status deteriorated postoperatively and he required several days of hospitalization. His medications included lasix 20 mg and prednisone 50 mg everyday, theophylline 300 mg twice a day, and diltiazem 30 mg three times a day. The patient’s physical examination was remarkable only for mild generalized wheezing. This had been noted on previous examinations and was thought to be representative of his baseline status. The preoperative ECG revealed Q waves in leads 2 and 3 and atrioventricular fibrillation; this was unchanged from three years previously. Pertinent lab data included a hemoglobin of 18.8 g/dl, normal clotting studies, and a theophylline level of 12 mcg/ml. Arterial blood-gas analysis while the patient was breathing room air revealed pH of 7.38, PaO, of 61 mmHg, a PaCO, of 55 mmHg, HCO, 32 mEq/L, BE + 6, and SpO, 90%. The chest radiograph showed no evidence of acute disease processes. Following discussion of the anesthetic plan with the
0952~8180/96,‘$15.00 PII SO952-8180(96)00019-0
patient he was brought to the operating room. Monitors included continuous EGG, SpO,, noninvasive blood pressure, precordial stethoscope, and end-tidal CO, through a set of nasal prongs. A lumbar epidural catheter was inserted at the L2-3 interspace with the patient in the lateral position. Following a negative test dose, 12 ml 2% lidoCaine with 1:200,000 epinephrine was given in divided doses to achieve the end point, which was relief of his leg and back pain. A sensory level to pin prick at T10 was noted. The patient was turned supine. At that point the patient stated he had “not felt this good” in years. A peribulbar block using the method described by Davis and Mandel’ was then accomplished using a total of 12 ml of a 50:50 mixture of 0.75% bupivicaine and 2% lidocaine with 150 units of hyaluronidase. Digital compression was applied for 10 minutes to avoid a rise in IOP following the block. The patient was positioned for the operation after application of a condom (Texas Catheter) for urinary drainage. Approximately 15 minutes after beginning the operation the patient coughed without any immediate problems. Shortly thereafter the eye was noted to be bulging with complete obliteration of the anterior chamber, preventing further surgery. The patient had been asked to try not to cough. It was presumed the patient was attempting to suppress further coughing, which was producing an increase in IOP. The patient informed us he was not trying to suppress a cough. The surgeon stated the eye was still protruding and surgery could not proceed. The patient was again quizzed and again responded he felt very comfortable and did not need to cough. The patient’s chest was auscultated, revealing clear breath sounds. Cardiac examination was also negative. There had been no noticeable change in blood pressure (BP), heart rate (HR), ECG, SpO,, or end-tidal CO,. The patient was still relieved of his back pain and a T-10 sensory level was still present. Further physical examination revealed that the patient apparently had a full urinary bladder. The patient tried and was unable to urinate, however, the eye appeared to bulge further with repeated attempts. A catheter was inserted into the patient’s bladder, draining 1,000 ml of urine and producing an immediate relaxation in the IOP. The rest of the operation proceeded without problems. Several hours later the patient experienced return to his previous level of back and leg pain. There was no change in his pulmonary status. Postoperatively his vision was significantly improved.
Discussion Most patients who require ophthalmic procedures are elderly and have multiple medical problems.’ Ophthalmic surgery is undertaken to improve quality of life, yet because of serious medical problems the procedures are not without risk. Perioperative mortality most often is due to cardiovascular events. Fortunately, the incidence is sign& cantly less than after nonophthalmic surgery.’ This lower incidence of morbidity or mortality cannot be attributed solely to the anesthetic technique. Three large retrospec-
tive studies did not provide conclusive evidence that a local/block technique versus a general anesthetic reduced Mortality was most often due to the patient’s morbidity.‘-4 underlying condition. Therefore, it would seem prudent to determine an anesthetic plan based on the patient’s ability to tolerate a given anesthetic technique that will provide adequate surgical conditions. Successful ophthalmic surgery often requires a motionless surgical field.’ This is best attained when a patient is under general anesthesia. Despite an adequate regional anesthetic technique for his first eye procedure, our patient had required a general anesthetic because his pain prevented him from remaining stationary. A second very important goal of ophthalmic anesthesia is to avoid increases in IOP.“X7 Factors that influence IOP include choroidal blood flow, vitreous volume, and extraocular muscle tone and aqueous humor fluid dynamics. Choroida1 blood flow is constant over a wide range of perfusion pressures but can increase transiently with sudden increases in systolic pressure. This would result in an increase in IOP. Our patient’s blood pressure was stable throughout the case. There was no change in the blood pressure before, during, or after the period of the increased IOP. Choroidal blood flow and hence the IOP is also elevated by a rise in the patient’s PaCO, or decrease in the PaO,. Residual effects of a general anesthetic could cause hypoventilation and hypercarbia. This patient’s pulmonary condition made him extremely susceptible to this problem. That is the reason a regional technique was selected for this operation. However, to tolerate his back and leg pain would probably have required significant intravenous medication to supplement the block for his eye surgery. The patient refused that plan, stating he did not think he would be comfortable with ‘tjust pain medication.” With epidural analgesia our patient did not require or receive any sedation during the case. End tidal CO, was monitored via a catheter through a set of nasal prongs. The initial values of PeCO, were elevated, as was expected because of his normal PaCO, of 55. The PeCO, values did not fluctuate more than 2 torr during this case. The SpO, was also stable at 90% to 92% throughout the case on 2 liters of oxygen through the nasal cannula. Sudden increases in venous pressure can also result in immediate changes in choroidal blood flow and IOP. Straining or coughing during emergence from general anesthesia with the effects on venous return can result in precipitous increases in IOP.“,7 That almost occurred after our patient’s first operation. The regional anesthetic technique was chosen to avoid possible coughing during emergence and extubation. Extraocular muscle contractions and compression of the globe can raise the IOP. Complete akinesia of the extraocular muscles achieved by the peribulbar block performed on this patient precluded that possibility. Another basis of IOP is an increased vitreous volume. Mannitol, an osmotic diuretic, is often given to reduce the vitreous volume. In this case the Foley was inserted and IOP quickly controlled. Therefore, an infusion of mannitol was not necessary. This made an increased vitreous volume unlikely as the cause of the IOP. J. Clin. Anesth., vol. 8, May 1996
249
Case Reports
Aqueous humor fluid can adversely affect IOP if drainage is impaired. The fluid eventually drains into the venous system. If the venous pressure is elevated and significantly reduces the drainage of the aqueous humor it could result in increased IOP. The patient did not have any signs or symptoms of an increased venous pressure. His HR and BP did not change. Physical examination did not reveal distended neck veins or any change in findings upon auscultation of both lung fields. It remains unclear exactly why this patient had an increased IOP. As noted he did not appear to have any of the usual conditions that have a detrimental affect on IOP. Our patient had a full urinary bladder and relief of that condition immediately reduced the IOP. A full bladder does not usually occur during ophthalmic surgery unless an osmotic diuretic has been given. Normally, patients do not receive a significant volume of intravenous fluids for this type of surgery. However, this patient was given a 500 ml fluid bolus prior to the epidural blockade, which could have resulted in an increased urine production. Distention of the bladder under general anesthesia can result in sympathetic response with elevations in HR and BP and increased IOP. The clinical manifestations of a full bladder of a patient under a regional anesthetic may not be as apparent because of a block of the sympathetic responses. The regional anesthetic could also blunt the patient’s awareness of a full bladder. This patient did not perceive any discomfort, nor did he exhibit any sympathetic responses to his distended bladder. We present a case of a patient with severe chronic medical conditions that made any conventional anesthetic
250
J. Glin. Anesth., vol. 8, May 1996
method for his ophthalmic surgery less than ideal. A combined technique of epidural and peribulbar blocks was employed. This method should be considered for similar patients to provide optimal patient comfort and safety and to meet the surgical requirements.” However, clinicians should be aware of the possible undesirable effect of this technique that our patient experienced. An evaluation of any intraoperative rise in IOP should include the possibility of a distended bladder that could be masked by the anesthetic technique.
References 1. Davis DB 2d, Mandel MR: Posterior peribulbar anesthesia: an alternative to retrobulbar anesthesia.] Cataract Rufmcinct Surg 1986;12: 182-4. 2. Backer CL, Tinker JH, Robertson DM, Vlietstra RE: Myocardial reinfarction following local anesthesia for ophthalmic surgery. An&h Annlg 1980;59:257-62. 3. Quigley HA. Mortality associated with ophthalmic surgery. A ‘LOyear experience at the Wilmer Institute. Am] O~hthnlmol 1974;77: 517-24. 4. Petruscak J, Smith RB, Breslin P: Mortality related to ophthalmological surgery. Arch Ophthnlmol 1973;89:106-9. 5. McColdrick KE: Principles of ophthalmic anesthesia. ,J Clin Anecth 1989;1:297-312. 6. Murphy DF: Anesthesia and intraocular pressure. rlnr\th Annlg 1985;64:520-30. and 7. Gmningham 47, Barry P: Intraocular pressure-physiology implications for anaesthetic management. Gut Annrsth SorJ 1986; 33:195-208. 8. Boskovski NA, Bormes P, Landers DF: Anesthetic management for the high-risk ophthalmic patient. ,J Clin Awrth 1992;4:39-41.
A Complication of Combined Regional Anesthesia Techniques for Ophthalmic Surgery Annie Joseph, MD, FFARCS,* Thomas M. Fuhrman, MD, MMSc, FCCMt Department of Anesthesiology, University of South Florida College of Medicine, and Bay Pines Veterans’ Administration Medical Center, Bay Pines, Florida.
Keywords: Combined regional medical problems; ophthalmic
techniques; surgery.
multiple
Introduction Ophthalmic operations often are performed on elderly patients with significant medical problems. As a result, there may be relative contraindications to either general or regional anesthesia techniques. A patient with debilitating chronic lung disease presented for cataract extraction and intraocular lens implantation. The patient also had persistent leg and back pain that prevented him from remaining stationary for even a short period of time. It was felt that a regional block anesthesia with sedation would be hazardous. Therefore, a combination of peribulbar and lumbar epidural anesthesia was performed. This resulted in excellent patient and operating conditions. However, the patient’s intraocular pressure (IOP) increased, necessitating a delay in the operative procedure. Ultimately, the bladder distention was relieved, allowing IOP to decrease, and the operation was completed.
Case Report A 64year-old obese (107 kg, 180 cm) white male presented with a two-year history of a cataract of the left eye.
*Assistant Professor tAssociate Professor Address reprint requests to Dr. Joseph at the Department of Anesthesiology, University of South Florida College of Medicine, 12901 Bruce B. Downs Blvd., MDC 59, Tampa, Florida 33612. Received for publication February 14, 1995; revised manuscript cepted for publication May 16, 1995.
Journal of Clinical Anesthesia 8:248-250, 1996 0 1996 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
ac-
The patient’s medical history included coronary artery disease with two previous myocardial infarctions 10 years earlier, chronic obstructive lung disease, glaucoma, and generalized osteoporosis secondary to his continuous use of steroids to treat his pulmonary disease. He had been admitted to the hospital numerous times for exacerbations of his pulmonary disease. The last admission for this problem was two months prior to this operation. Although the patient denied angina, he had only minimal exercise tolerance. His pulmonary condition caused him to be chronically short of breath. He was unable to walk, ambulating only with the aid of a wheelchair due to relentless back, hip, and leg pain. This pain was so severe that he could not tolerate his previous ophthalmic procedure under a nerve block and required a general anesthetic intraoperatively. That operation was successful but was complicated by significant coughing on emergence and aggravation of his leg and back pain. In addition, his pulmonary status deteriorated postoperatively and he required several days of hospitalization. His medications included lasix 20 mg and prednisone 50 mg everyday, theophylline 300 mg twice a day, and diltiazem 30 mg three times a day. The patient’s physical examination was remarkable only for mild generalized wheezing. This had been noted on previous examinations and was thought to be representative of his baseline status. The preoperative ECG revealed Q waves in leads 2 and 3 and atrioventricular fibrillation; this was unchanged from three years previously. Pertinent lab data included a hemoglobin of 18.8 g/dl, normal clotting studies, and a theophylline level of 12 mcg/ml. Arterial blood-gas analysis while the patient was breathing room air revealed pH of 7.38, PaO, of 61 mmHg, a PaCO, of 55 mmHg, HCO, 32 mEq/L, BE + 6, and SpO, 90%. The chest radiograph showed no evidence of acute disease processes. Following discussion of the anesthetic plan with the
0952~8180/96,‘$15.00 PII SO952-8180(96)00019-0
patient he was brought to the operating room. Monitors included continuous EGG, SpO,, noninvasive blood pressure, precordial stethoscope, and end-tidal CO, through a set of nasal prongs. A lumbar epidural catheter was inserted at the L2-3 interspace with the patient in the lateral position. Following a negative test dose, 12 ml 2% lidoCaine with 1:200,000 epinephrine was given in divided doses to achieve the end point, which was relief of his leg and back pain. A sensory level to pin prick at T10 was noted. The patient was turned supine. At that point the patient stated he had “not felt this good” in years. A peribulbar block using the method described by Davis and Mandel’ was then accomplished using a total of 12 ml of a 50:50 mixture of 0.75% bupivicaine and 2% lidocaine with 150 units of hyaluronidase. Digital compression was applied for 10 minutes to avoid a rise in IOP following the block. The patient was positioned for the operation after application of a condom (Texas Catheter) for urinary drainage. Approximately 15 minutes after beginning the operation the patient coughed without any immediate problems. Shortly thereafter the eye was noted to be bulging with complete obliteration of the anterior chamber, preventing further surgery. The patient had been asked to try not to cough. It was presumed the patient was attempting to suppress further coughing, which was producing an increase in IOP. The patient informed us he was not trying to suppress a cough. The surgeon stated the eye was still protruding and surgery could not proceed. The patient was again quizzed and again responded he felt very comfortable and did not need to cough. The patient’s chest was auscultated, revealing clear breath sounds. Cardiac examination was also negative. There had been no noticeable change in blood pressure (BP), heart rate (HR), ECG, SpO,, or end-tidal CO,. The patient was still relieved of his back pain and a T-10 sensory level was still present. Further physical examination revealed that the patient apparently had a full urinary bladder. The patient tried and was unable to urinate, however, the eye appeared to bulge further with repeated attempts. A catheter was inserted into the patient’s bladder, draining 1,000 ml of urine and producing an immediate relaxation in the IOP. The rest of the operation proceeded without problems. Several hours later the patient experienced return to his previous level of back and leg pain. There was no change in his pulmonary status. Postoperatively his vision was significantly improved.
Discussion Most patients who require ophthalmic procedures are elderly and have multiple medical problems.’ Ophthalmic surgery is undertaken to improve quality of life, yet because of serious medical problems the procedures are not without risk. Perioperative mortality most often is due to cardiovascular events. Fortunately, the incidence is sign& cantly less than after nonophthalmic surgery.’ This lower incidence of morbidity or mortality cannot be attributed solely to the anesthetic technique. Three large retrospec-
tive studies did not provide conclusive evidence that a local/block technique versus a general anesthetic reduced Mortality was most often due to the patient’s morbidity.‘-4 underlying condition. Therefore, it would seem prudent to determine an anesthetic plan based on the patient’s ability to tolerate a given anesthetic technique that will provide adequate surgical conditions. Successful ophthalmic surgery often requires a motionless surgical field.’ This is best attained when a patient is under general anesthesia. Despite an adequate regional anesthetic technique for his first eye procedure, our patient had required a general anesthetic because his pain prevented him from remaining stationary. A second very important goal of ophthalmic anesthesia is to avoid increases in IOP.“X7 Factors that influence IOP include choroidal blood flow, vitreous volume, and extraocular muscle tone and aqueous humor fluid dynamics. Choroida1 blood flow is constant over a wide range of perfusion pressures but can increase transiently with sudden increases in systolic pressure. This would result in an increase in IOP. Our patient’s blood pressure was stable throughout the case. There was no change in the blood pressure before, during, or after the period of the increased IOP. Choroidal blood flow and hence the IOP is also elevated by a rise in the patient’s PaCO, or decrease in the PaO,. Residual effects of a general anesthetic could cause hypoventilation and hypercarbia. This patient’s pulmonary condition made him extremely susceptible to this problem. That is the reason a regional technique was selected for this operation. However, to tolerate his back and leg pain would probably have required significant intravenous medication to supplement the block for his eye surgery. The patient refused that plan, stating he did not think he would be comfortable with ‘tjust pain medication.” With epidural analgesia our patient did not require or receive any sedation during the case. End tidal CO, was monitored via a catheter through a set of nasal prongs. The initial values of PeCO, were elevated, as was expected because of his normal PaCO, of 55. The PeCO, values did not fluctuate more than 2 torr during this case. The SpO, was also stable at 90% to 92% throughout the case on 2 liters of oxygen through the nasal cannula. Sudden increases in venous pressure can also result in immediate changes in choroidal blood flow and IOP. Straining or coughing during emergence from general anesthesia with the effects on venous return can result in precipitous increases in IOP.“,7 That almost occurred after our patient’s first operation. The regional anesthetic technique was chosen to avoid possible coughing during emergence and extubation. Extraocular muscle contractions and compression of the globe can raise the IOP. Complete akinesia of the extraocular muscles achieved by the peribulbar block performed on this patient precluded that possibility. Another basis of IOP is an increased vitreous volume. Mannitol, an osmotic diuretic, is often given to reduce the vitreous volume. In this case the Foley was inserted and IOP quickly controlled. Therefore, an infusion of mannitol was not necessary. This made an increased vitreous volume unlikely as the cause of the IOP. J. Clin. Anesth., vol. 8, May 1996
249
Case Reports
Aqueous humor fluid can adversely affect IOP if drainage is impaired. The fluid eventually drains into the venous system. If the venous pressure is elevated and significantly reduces the drainage of the aqueous humor it could result in increased IOP. The patient did not have any signs or symptoms of an increased venous pressure. His HR and BP did not change. Physical examination did not reveal distended neck veins or any change in findings upon auscultation of both lung fields. It remains unclear exactly why this patient had an increased IOP. As noted he did not appear to have any of the usual conditions that have a detrimental affect on IOP. Our patient had a full urinary bladder and relief of that condition immediately reduced the IOP. A full bladder does not usually occur during ophthalmic surgery unless an osmotic diuretic has been given. Normally, patients do not receive a significant volume of intravenous fluids for this type of surgery. However, this patient was given a 500 ml fluid bolus prior to the epidural blockade, which could have resulted in an increased urine production. Distention of the bladder under general anesthesia can result in sympathetic response with elevations in HR and BP and increased IOP. The clinical manifestations of a full bladder of a patient under a regional anesthetic may not be as apparent because of a block of the sympathetic responses. The regional anesthetic could also blunt the patient’s awareness of a full bladder. This patient did not perceive any discomfort, nor did he exhibit any sympathetic responses to his distended bladder. We present a case of a patient with severe chronic medical conditions that made any conventional anesthetic
250
J. Glin. Anesth., vol. 8, May 1996
method for his ophthalmic surgery less than ideal. A combined technique of epidural and peribulbar blocks was employed. This method should be considered for similar patients to provide optimal patient comfort and safety and to meet the surgical requirements.” However, clinicians should be aware of the possible undesirable effect of this technique that our patient experienced. An evaluation of any intraoperative rise in IOP should include the possibility of a distended bladder that could be masked by the anesthetic technique.
References 1. Davis DB 2d, Mandel MR: Posterior peribulbar anesthesia: an alternative to retrobulbar anesthesia.] Cataract Rufmcinct Surg 1986;12: 182-4. 2. Backer CL, Tinker JH, Robertson DM, Vlietstra RE: Myocardial reinfarction following local anesthesia for ophthalmic surgery. An&h Annlg 1980;59:257-62. 3. Quigley HA. Mortality associated with ophthalmic surgery. A ‘LOyear experience at the Wilmer Institute. Am] O~hthnlmol 1974;77: 517-24. 4. Petruscak J, Smith RB, Breslin P: Mortality related to ophthalmological surgery. Arch Ophthnlmol 1973;89:106-9. 5. McColdrick KE: Principles of ophthalmic anesthesia. ,J Clin Anecth 1989;1:297-312. 6. Murphy DF: Anesthesia and intraocular pressure. rlnr\th Annlg 1985;64:520-30. and 7. Gmningham 47, Barry P: Intraocular pressure-physiology implications for anaesthetic management. Gut Annrsth SorJ 1986; 33:195-208. 8. Boskovski NA, Bormes P, Landers DF: Anesthetic management for the high-risk ophthalmic patient. ,J Clin Awrth 1992;4:39-41.