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Probing for nasolacrimal duct obstruction with intravenous propofol sedation
Probing for Nasolacrimal Duct Obstruction With Intravenous Propofol Sedation Mansour Movaghar, MD,a Sylvia Kodsi, MD,a,b Craig Merola, MD,b and James Doyle, MDa Background: Nasolacrimal duct obstruction occurs in 5% to 6% of neonates. Many studies advocate the probing of nasolacrimal duct obstruction under general inhalational anesthesia in patients at a late age (12 to 13 months) because a high percentage will resolve spontaneously. Others support early surgical intervention in patients aged younger than 6 to 9 months without anesthesia. We present late nasolacrimal duct probing under intravenous propofol sedation as an alternative approach to the treatment of nasolacrimal duct obstruction with a decrease in cost and time compared with probing under general inhalational anesthesia. Methods: We made a retrospective review of patient charts of children who underwent nasolacrimal duct probing with intravenous propofol sedation from April 1996 to September 1997. Procedure time and cost of procedure were compared for patients who had probings under propofol sedation to patients who had probings under general anesthesia. Results: A total of 22 patients (31 eyes) underwent nasolacrimal duct probing with propofol sedation; the patients’ ages ranged from 11.5 to 39 months (average age, 17.8 months). Twenty-six (84%) of 31 eyes had resolution of the symptoms. The average total time for procedure under propofol sedation was 10.5 minutes, compared with 43.6 minutes under general inhalational anesthesia. The average total recovery time under propofol sedation was 13.6 minutes, compared with 121.1 minutes with general inhalational anesthesia. The cost of probing under propofol sedation was one third less than the cost of probing under general inhalational anesthesia. Discussion: Late probing for nasolacrimal duct obstruction under intravenous propofol sedation is comparable in efficacy to late probing under general inhalational anesthesia with a shorter time for the procedure and decreased expense. (J AAPOS 2000;4:179-82)
N
asolacrimal duct obstruction occurs in approximately 5% to 6% of neonates.1 A number of studies advocate medical management, consisting of topical antibiotics, nasolacrimal duct massage, and delay of nasolacrimal duct probing, until the patients’ ages are 12 to 13 months, because a high percentage of obstructions will spontaneously resolve by that age.2-7 Others support early surgical intervention before the patients are aged 6 to 9 months.8-11 Probing for nasolacrimal duct obstruction is usually performed in patients either early (younger than 6 months) in the office under restraint or late (older than 1 year) under general inhalational anesthesia. Early officebased probing is brief and avoids the costs and risks of general inhalational anesthesia. However, many children are subjected to an unnecessary procedure because most of these obstructions will spontaneously resolve by 1 year of From the Department of Ophthalmologya and the Department of Pediatrics,b Long Island Jewish Medical Center, New Hyde Park, New York. Submitted March 16, 1999. Revision accepted October 5, 1999. Reprint requests: Sylvia Kodsi, MD, 600 Northern Boulevard, Suite 214, Great Neck, NY 11021 (e-mail: [email protected]). Copyright © 2000 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/2000/$12.00 + 0 75/1/103871 doi:10.1067/mpa.2000.103871
Journal of AAPOS
age. Late probing under general inhalational anesthesia offers a more controlled setting and subjects fewer patients to the procedure by awaiting spontaneous resolution. However, the cost of probing under general inhalational anesthesia is greater, the total time for the procedure is longer, and there is a small but significant risk of general inhalational anesthesia.12 Intravenous propofol has been used at our institution recently to sedate children for imaging studies and brief painful procedures.13-16 Subsequently, we have performed probings for nasolacrimal duct obstruction under intravenous propofol sedation. We present late nasolacrimal duct probing under propofol sedation as an alternative, successful procedure for nasolacrimal duct obstruction, with a decrease in cost and time, compared with probing under general inhalational anesthesia.
PATIENTS AND METHODS The private patient files of two of the authors (S.K. and J.D.) from April 1996 to September 1997 were reviewed, identifying all patients who had a probing for nasolacrimal duct obstruction under intravenous propofol sedation. All children who had nasolacrimal duct obstruction and failed conservative treatment had probings under intravenous propofol sedation. Exclusion criteria were significant cardiac, pulmonary, or craniofacial abnormalities.
June 2000
179
Journal of AAPOS Volume 4 Number 3 June 2000
180 Movaghar et al TABLE. Success of initial probing by age group and number of eyes probed Age (mo)
Katowitz5
Robb7
0 to 6 6 to 13 13 to 18 18 to 24 Over 24
98.2% (58) 95.5% (219) 76.8% (69) 54.1% (37) 33.3% (63)
None 94.9% (39) 88.6% (44) 87.5% (8) 84.6% (13)
Stager9*
Movaghar
95%(1427) None 88.5% (823) 100% (6) 86.5% (119) 83.3% (18) None 100% (1) None 66.7% (6)
*Stager’s age groups were 1 to 6, 6 to 12, and >12 months. Probings were all office based and without anesthesia.
A complete history and ophthalmic evaluation were performed on each patient. Evaluations of the tear film, epiphora, crusting of lashes, dye disappearance test, and mucopurulent discharge on lacrimal sac massage were noted. Preoperatively, all patients had a positive result from the dye disappearance test or frank mucopurulent discharge from the lacrimal sac. The probings were performed in a treatment room at Schneider Children’s Hospital. We used the protocol already established at our institution for procedures involving propofol sedation.14,15 The children could eat solid foods up to 8 hours before the procedure. Clear liquids were allowed up to 2 hours before the procedure. The children could have nothing by mouth 2 hours before the procedure. An intravenous line was established for the administration of propofol. Oxygen was given by nasal cannula while oxygen saturation was monitored with pulse oximetry. The patients received a bolus dose of 2 mg/kg of propofol intravenously, which prevented spontaneous movement as well as most movement in response to manipulation. Subsequent smaller boluses were given as needed to maintain sedation. Topical anesthetic drops were placed in the affected eye. The inferior or superior punctum was dilated using a sterile safety pin and/or a punctum dilator. A 00-Bowman probe was passed through the inferior or superior canalicular system, nasolacrimal sac, and nasolacrimal duct. A combination antibiotic/steroid drop was administered on completion of the probing. Patients were transferred to the recovery area once they were awake. The children were discharged from the hospital when their scores, using the Aldrete criteria for postprocedure recovery, were 10 or baseline; when vital signs were stable; when temperature was normal; and when they could tolerate fluids by mouth. Also, if appropriate for the age of the child, the child should be able to talk and sit without assistance. Procedure time and recovery time were recorded in all patients who underwent probing with propofol sedation and compared with a group of 7 patients who had probing under general inhalational anesthesia with either endotracheal intubation or a laryngeal mask. For the probings performed under propofol sedation, procedure time was defined as the time in the treatment room for the procedure, which included placement of the intravenous line,
administration of propofol, probing, and recovery to alertness to be transferred to the recovery area, whereas recovery time was defined as the time spent in the recovery area before discharge from the hospital. For probings under general anesthesia, procedure time was defined as the time spent in the operating room whereas recovery time was defined as the time spent in the recovery room before discharge from the hospital. The cost of the procedure was obtained from the hospital billing system for the probings performed under intravenous propofol sedation and for the probings performed under general inhalational anesthesia. All patients were seen 1 to 4 weeks postoperatively. A negative result from a dye disappearance test and a resolution of symptoms constituted a successful procedure. A recurrence of symptoms with a positive result from a dye disappearance test constituted a failure of the procedure.
RESULTS A total of 22 patients (31 eyes) underwent initial nasolacrimal duct probing with propofol sedation. Age at probing ranged from 11.5 to 39 months (average age, 17.8 months). In the group aged 6 to 13 months (4 patients), 6 (100%) of 6 eyes had total resolution of symptoms after the initial probing. In the group aged 13 to 18 months (13 patients), 15 (83.3%) of 18 eyes had total resolution after the initial probing. Of the 3 eyes in the group aged 13 to 18 months that failed the initial probing, two had resolution of symptoms after repeat nasolacrimal duct probing under intravenous propofol sedation, and one had resolution of symptoms after nasolacrimal duct probing under general anesthesia. In the group aged 18 to 24 months (1 patient), 1 (100%) of 1 eye had total resolution after the initial probing. In the group older than 24 months (4 patients), 4 (66.7%) of 6 eyes had total resolution after the initial probing. Of the 2 eyes that failed the initial probing in the group older than 24 months, both had resolution after placement of silicone tubes. For the patients who had probings under propofol sedation, the average procedure time was 10.5 minutes, and the average recovery time was 13.6 minutes. The total time for the procedure and recovery under propofol sedation was 24.1 minutes. In the patient group that had probing done under general inhalational anesthesia, the average procedure time was 43.6 minutes, and the average recovery time was 121.1 minutes. Therefore, the total time for the procedure and recovery was 164.7 minutes. Schneider Children’s Hospital charged $2988 for a probing under general inhalational anesthesia in 1997 compared with $1958 for a probing under propofol sedation. The probing under propofol sedation is $1030, or one third less.
DISCUSSION The success rate of nasolacrimal duct probing under intravenous propofol sedation is comparable to the success rates achieved by Katowitz and Welsh5 and Robb7 under general inhalational anesthesia (Table). The success rate is
Journal of AAPOS Volume 4 Number 3 June 2000
also similar when compared with Stager et al9 who probed in the office under restraint. Stager’s data were on slightly different age groups because he looked at patients aged 1 to 6 months, patients aged 6 to 12 months, and patients 12 months and older without differentiating the last group. The 31 eyes probed in this report do not lend to statistical significance on the basis of the low number, but the success rates appear similar. A significant benefit of probing under propofol sedation is less time in the hospital for the procedure. Under propofol sedation the procedure lasted, on average, only 10.5 minutes, and on average, recovery time was only 13.6 minutes with a total average time in the hospital of 24.1 minutes. The average amount of time was much less compared with general inhalational anesthesia, which was, on average, 43.6 minutes for the procedure and 121.1 minutes in the recovery room with a total average time in the hospital of approximately 164.7 minutes. Because propofol is metabolized so rapidly, the child does not need much monitoring postoperatively. Propofol sedation allows for improved physician control during the procedure because the ophthalmologist has a better feel and visualization of the anatomy compared with struggling with a restrained child. However, the control obtained with intravenous propofol sedation is not equal to that of general inhalational anesthesia, and often there is some movement of the child. The authors at this time have not used this method for resident teaching because of resident inexperience and decreased control compared with general anesthesia. We would also not advocate this method for an ophthalmologist who rarely performs probing of the nasolacrimal duct. The authors worry that the decreased control in the hands of an inexperienced surgeon may lead to an increased risk of ocular complications that can occur with probing of the nasolacrimal duct, which include creation of a false passage with subsequent preseptal cellulitis, canalicular laceration, and damage to puncta. There were no ocular complications of this or any type in the 31 eyes probed under propofol sedation. Intravenous propofol has safely been used since 1989 when it was approved by the US Food and Drug Administration as an induction agent and a method for continuous intravenous sedation.13 Propofol has also been used for pediatric sedation as an alternative to pentobarbital, Demerol-Phenergan-Thorazine, choral hydrate, and ketamine.13-16 Propofol is rapidly distributed in the body and metabolized, resulting in a very short-acting agent.13 Rapid onset of sedation and emergence from sedation occur with minimal anesthetic hangover.17 Disadvantages to the administration of propofol include burning or discomfort at the site of infusion.18 Supplemental oxygen must be administered once the child is sedated because propofol depresses ventilation and can cause apnea and hypoxia.17 An important consideration is cost, which is coming to the forefront in the new managed care environment. Paul
Movaghar et al
181
and Shepherd10 mathematically modeled the relative cost of several strategies for probing and concluded that delaying intervention until just before the risk of probing in the office becomes unacceptable is the best choice. Kassoff and Meyer11 advocate early probing (6 months) in the office over probing in the hospital under general inhalational anesthesia (12 months), despite equal success rates, because the cost of probing under general inhalational anesthesia is 10 times greater. The probing under propofol sedation is $1030, or one third less than under general anesthesia. The lower cost is due to the lower anesthesiologist’s bill, very limited anesthesia and operative supplies, and the lack of recovery room time. Although both costs are high, there is still a significant savings performing the probing under propofol sedation. A disadvantage to the use of intravenous propofol sedation is the requirement of an anesthesiologist who feels comfortable placing an intravenous line in a conscious infant and administering propofol. At Schneider Children’s Hospital, one of the authors (C.M.) exclusively administers analgesics and sedatives without intubation or inhalational anesthetics for minimally invasive procedures or tests for which a child cannot cooperate such as probing of the nasolacrimal duct, endoscopy, lumbar puncture, cardiac catheterization, magnetic resonance imaging, electroencephalograms, and many other tests. Only a children’s hospital or a very large hospital can financially support a full-time anesthesiologist for sedation of children for various procedures or tests. Another disadvantage with intravenous propofol sedation is that verification of patency of the nasolacrimal duct is not possible in this setting. Irrigation of the nasolacrimal duct was avoided to decrease the risk of laryngospasm. Attempts at verification with “metal on metal contact” under the inferior turbinate caused the patient too much discomfort even with propofol sedation. Although we only discuss the use of intravenous propofol sedation for probing of the nasolacrimal duct, our ophthalmology department has used intravenous propofol sedation for ocular examinations under anesthesia, removal of corneal sutures and foreign bodies, and laser treatment of traumatic retinal tears. Intravenous propofol allows for sedation and amnesia; however, it does not provide adequate analgesia and would not be useful if the procedure caused pain and required no movement from the patient (eg, subtenons injection). Intravenous propofol is not an ideal sedative to use to measure intraocular pressure, since it can cause a significant decrease in intraocular pressure ranging from 27% to 53%.17 In summary, late probing of the nasolacrimal duct under intravenous propofol sedation is effective, is a shorter procedure, and is less expensive compared with late probing under general inhalational anesthesia. Although the cost per patient of late probing under intravenous propofol sedation is greater compared with early officebased probing, the relative cost or the total cost to the
Journal of AAPOS Volume 4 Number 3 June 2000
182 Movaghar et al health care system may be less if probing is delayed until 1 year of age, because early probing under restraint subjects many children to a procedure for a problem that may spontaneously resolve by 1 year of age. We wish to thank Cindy Albarracin, RN, for her help with this project.
11.
12.
References 1. Guerry D III, Dendig EL Jr. Congenital impatency of the nasolacrimal duct. Arch Ophthalmol 1948;39:193-204. 2. Nelson LB, Calhoun JH, Menduke H. Medical management of congenital nasolacrimal duct obstruction. Ophthalmology 1985;92: 1187-90. 3. Petersen RA, Robb RM. The natural course of congenital obstruction of the nasolacrimal duct. J Pediatr Ophthalmol Strabismus 1978;15:246-50. 4. Paul TO. Medical management of congenital nasolacrimal duct obstruction. J Pediatr Ophthalmol Strabismus 1985;22:68-70. 5. Katowitz JA, Welsh MG. Timing of initial probing and irrigation in congenital nasolacrimal duct obstruction. Ophthalmology 1987;94: 698-705. 6. Nucci P, Capoferri C, Alfarano R, Brancato R. Conservative management of congenital nasolacrimal duct obstruction. J Pediatr Ophthalmol Strabismus 1989;26:39-43. 7. Robb RM. Probing and irrigation for congenital nasolacrimal duct obstruction. Arch Ophthalmol 1986;104:378-9. 8. Kushner BJ. Congenital nasolacrimal system obstruction. Arch Ophthalmol 1982;110:597-600. 9. Stager D, Baker JD, Frey T, Weakley DR Jr, Birch EE. Office prob-
O
10.
13.
14.
15.
16.
17. 18.
ing of congenital nasolacrimal duct obstruction. Ophthalmic Surg 1992;23:482-4. Paul TO, Sheperd R. Congenital nasolacrimal duct obstruction: natural history and the timing of optimal intervention. J Pediatr Ophthalmol Strabismus 1994;31:362-7. Kasssoff J, Meyer DR. Early office-based vs late hospital-based nasolacrimal duct probing: a clinical decision analysis. Arch Ophthalmol 1995;113:1168-71. Tiret L, Nivoche Y, Hatton F, Desmonts JM, Vourc’h G. Complications related to anaesthesia in infants and children: a prospective survey of 40240 anaesthetics. Br J Anaesth 1988;61: 263-9. Bloomfield EL, Masaryk TJ, Caplin A, Obuchowski NA, Schubert A, Hayden J, et al. Intravenous sedation for MR imaging of the brain and spine in children: pentobarbital versus propofol. Radiology 1993;186:93-7. Barst SM, Merola CM, Kandell LG, Markowitz AE, Duroseau M, Karayalcin G, et al. A comparison of propofol and demerol-phenergan-thorazine for brief, minor, painful procedures in a pediatric hematology-oncology clinic. Int J Pediatr Hematol Oncol 1995;1: 587-91. Merola CM, Albarracin C, Lebowitz P, Bienkowski RS, Barst SM. An audit of adverse events in children sedated with chloral hydrate or propofol during imaging studies. Paediatr Anaesth 1995;5:375-8. Lebovic S, Reich DL, Steinberg LG, Vela FP, Silvay G. Comparison of propofol versus ketamine for anesthesia in pediatric patients undergoing cardiac catheterization. Anesth Analg 1992;74:490-4. Sebel PS, Lowdon JD. Propofol: a new intravenous anesthetic. Anesthesiology 1989;71:260-77. Mirakhur RK. Induction characteristics of propofol in children: comparison with thiopentone. Anaesthesia 1988;43:593-8.
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N
asolacrimal duct obstruction occurs in approximately 5% to 6% of neonates.1 A number of studies advocate medical management, consisting of topical antibiotics, nasolacrimal duct massage, and delay of nasolacrimal duct probing, until the patients’ ages are 12 to 13 months, because a high percentage of obstructions will spontaneously resolve by that age.2-7 Others support early surgical intervention before the patients are aged 6 to 9 months.8-11 Probing for nasolacrimal duct obstruction is usually performed in patients either early (younger than 6 months) in the office under restraint or late (older than 1 year) under general inhalational anesthesia. Early officebased probing is brief and avoids the costs and risks of general inhalational anesthesia. However, many children are subjected to an unnecessary procedure because most of these obstructions will spontaneously resolve by 1 year of From the Department of Ophthalmologya and the Department of Pediatrics,b Long Island Jewish Medical Center, New Hyde Park, New York. Submitted March 16, 1999. Revision accepted October 5, 1999. Reprint requests: Sylvia Kodsi, MD, 600 Northern Boulevard, Suite 214, Great Neck, NY 11021 (e-mail: [email protected]). Copyright © 2000 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/2000/$12.00 + 0 75/1/103871 doi:10.1067/mpa.2000.103871
Journal of AAPOS
age. Late probing under general inhalational anesthesia offers a more controlled setting and subjects fewer patients to the procedure by awaiting spontaneous resolution. However, the cost of probing under general inhalational anesthesia is greater, the total time for the procedure is longer, and there is a small but significant risk of general inhalational anesthesia.12 Intravenous propofol has been used at our institution recently to sedate children for imaging studies and brief painful procedures.13-16 Subsequently, we have performed probings for nasolacrimal duct obstruction under intravenous propofol sedation. We present late nasolacrimal duct probing under propofol sedation as an alternative, successful procedure for nasolacrimal duct obstruction, with a decrease in cost and time, compared with probing under general inhalational anesthesia.
PATIENTS AND METHODS The private patient files of two of the authors (S.K. and J.D.) from April 1996 to September 1997 were reviewed, identifying all patients who had a probing for nasolacrimal duct obstruction under intravenous propofol sedation. All children who had nasolacrimal duct obstruction and failed conservative treatment had probings under intravenous propofol sedation. Exclusion criteria were significant cardiac, pulmonary, or craniofacial abnormalities.
June 2000
179
Journal of AAPOS Volume 4 Number 3 June 2000
180 Movaghar et al TABLE. Success of initial probing by age group and number of eyes probed Age (mo)
Katowitz5
Robb7
0 to 6 6 to 13 13 to 18 18 to 24 Over 24
98.2% (58) 95.5% (219) 76.8% (69) 54.1% (37) 33.3% (63)
None 94.9% (39) 88.6% (44) 87.5% (8) 84.6% (13)
Stager9*
Movaghar
95%(1427) None 88.5% (823) 100% (6) 86.5% (119) 83.3% (18) None 100% (1) None 66.7% (6)
*Stager’s age groups were 1 to 6, 6 to 12, and >12 months. Probings were all office based and without anesthesia.
A complete history and ophthalmic evaluation were performed on each patient. Evaluations of the tear film, epiphora, crusting of lashes, dye disappearance test, and mucopurulent discharge on lacrimal sac massage were noted. Preoperatively, all patients had a positive result from the dye disappearance test or frank mucopurulent discharge from the lacrimal sac. The probings were performed in a treatment room at Schneider Children’s Hospital. We used the protocol already established at our institution for procedures involving propofol sedation.14,15 The children could eat solid foods up to 8 hours before the procedure. Clear liquids were allowed up to 2 hours before the procedure. The children could have nothing by mouth 2 hours before the procedure. An intravenous line was established for the administration of propofol. Oxygen was given by nasal cannula while oxygen saturation was monitored with pulse oximetry. The patients received a bolus dose of 2 mg/kg of propofol intravenously, which prevented spontaneous movement as well as most movement in response to manipulation. Subsequent smaller boluses were given as needed to maintain sedation. Topical anesthetic drops were placed in the affected eye. The inferior or superior punctum was dilated using a sterile safety pin and/or a punctum dilator. A 00-Bowman probe was passed through the inferior or superior canalicular system, nasolacrimal sac, and nasolacrimal duct. A combination antibiotic/steroid drop was administered on completion of the probing. Patients were transferred to the recovery area once they were awake. The children were discharged from the hospital when their scores, using the Aldrete criteria for postprocedure recovery, were 10 or baseline; when vital signs were stable; when temperature was normal; and when they could tolerate fluids by mouth. Also, if appropriate for the age of the child, the child should be able to talk and sit without assistance. Procedure time and recovery time were recorded in all patients who underwent probing with propofol sedation and compared with a group of 7 patients who had probing under general inhalational anesthesia with either endotracheal intubation or a laryngeal mask. For the probings performed under propofol sedation, procedure time was defined as the time in the treatment room for the procedure, which included placement of the intravenous line,
administration of propofol, probing, and recovery to alertness to be transferred to the recovery area, whereas recovery time was defined as the time spent in the recovery area before discharge from the hospital. For probings under general anesthesia, procedure time was defined as the time spent in the operating room whereas recovery time was defined as the time spent in the recovery room before discharge from the hospital. The cost of the procedure was obtained from the hospital billing system for the probings performed under intravenous propofol sedation and for the probings performed under general inhalational anesthesia. All patients were seen 1 to 4 weeks postoperatively. A negative result from a dye disappearance test and a resolution of symptoms constituted a successful procedure. A recurrence of symptoms with a positive result from a dye disappearance test constituted a failure of the procedure.
RESULTS A total of 22 patients (31 eyes) underwent initial nasolacrimal duct probing with propofol sedation. Age at probing ranged from 11.5 to 39 months (average age, 17.8 months). In the group aged 6 to 13 months (4 patients), 6 (100%) of 6 eyes had total resolution of symptoms after the initial probing. In the group aged 13 to 18 months (13 patients), 15 (83.3%) of 18 eyes had total resolution after the initial probing. Of the 3 eyes in the group aged 13 to 18 months that failed the initial probing, two had resolution of symptoms after repeat nasolacrimal duct probing under intravenous propofol sedation, and one had resolution of symptoms after nasolacrimal duct probing under general anesthesia. In the group aged 18 to 24 months (1 patient), 1 (100%) of 1 eye had total resolution after the initial probing. In the group older than 24 months (4 patients), 4 (66.7%) of 6 eyes had total resolution after the initial probing. Of the 2 eyes that failed the initial probing in the group older than 24 months, both had resolution after placement of silicone tubes. For the patients who had probings under propofol sedation, the average procedure time was 10.5 minutes, and the average recovery time was 13.6 minutes. The total time for the procedure and recovery under propofol sedation was 24.1 minutes. In the patient group that had probing done under general inhalational anesthesia, the average procedure time was 43.6 minutes, and the average recovery time was 121.1 minutes. Therefore, the total time for the procedure and recovery was 164.7 minutes. Schneider Children’s Hospital charged $2988 for a probing under general inhalational anesthesia in 1997 compared with $1958 for a probing under propofol sedation. The probing under propofol sedation is $1030, or one third less.
DISCUSSION The success rate of nasolacrimal duct probing under intravenous propofol sedation is comparable to the success rates achieved by Katowitz and Welsh5 and Robb7 under general inhalational anesthesia (Table). The success rate is
Journal of AAPOS Volume 4 Number 3 June 2000
also similar when compared with Stager et al9 who probed in the office under restraint. Stager’s data were on slightly different age groups because he looked at patients aged 1 to 6 months, patients aged 6 to 12 months, and patients 12 months and older without differentiating the last group. The 31 eyes probed in this report do not lend to statistical significance on the basis of the low number, but the success rates appear similar. A significant benefit of probing under propofol sedation is less time in the hospital for the procedure. Under propofol sedation the procedure lasted, on average, only 10.5 minutes, and on average, recovery time was only 13.6 minutes with a total average time in the hospital of 24.1 minutes. The average amount of time was much less compared with general inhalational anesthesia, which was, on average, 43.6 minutes for the procedure and 121.1 minutes in the recovery room with a total average time in the hospital of approximately 164.7 minutes. Because propofol is metabolized so rapidly, the child does not need much monitoring postoperatively. Propofol sedation allows for improved physician control during the procedure because the ophthalmologist has a better feel and visualization of the anatomy compared with struggling with a restrained child. However, the control obtained with intravenous propofol sedation is not equal to that of general inhalational anesthesia, and often there is some movement of the child. The authors at this time have not used this method for resident teaching because of resident inexperience and decreased control compared with general anesthesia. We would also not advocate this method for an ophthalmologist who rarely performs probing of the nasolacrimal duct. The authors worry that the decreased control in the hands of an inexperienced surgeon may lead to an increased risk of ocular complications that can occur with probing of the nasolacrimal duct, which include creation of a false passage with subsequent preseptal cellulitis, canalicular laceration, and damage to puncta. There were no ocular complications of this or any type in the 31 eyes probed under propofol sedation. Intravenous propofol has safely been used since 1989 when it was approved by the US Food and Drug Administration as an induction agent and a method for continuous intravenous sedation.13 Propofol has also been used for pediatric sedation as an alternative to pentobarbital, Demerol-Phenergan-Thorazine, choral hydrate, and ketamine.13-16 Propofol is rapidly distributed in the body and metabolized, resulting in a very short-acting agent.13 Rapid onset of sedation and emergence from sedation occur with minimal anesthetic hangover.17 Disadvantages to the administration of propofol include burning or discomfort at the site of infusion.18 Supplemental oxygen must be administered once the child is sedated because propofol depresses ventilation and can cause apnea and hypoxia.17 An important consideration is cost, which is coming to the forefront in the new managed care environment. Paul
Movaghar et al
181
and Shepherd10 mathematically modeled the relative cost of several strategies for probing and concluded that delaying intervention until just before the risk of probing in the office becomes unacceptable is the best choice. Kassoff and Meyer11 advocate early probing (6 months) in the office over probing in the hospital under general inhalational anesthesia (12 months), despite equal success rates, because the cost of probing under general inhalational anesthesia is 10 times greater. The probing under propofol sedation is $1030, or one third less than under general anesthesia. The lower cost is due to the lower anesthesiologist’s bill, very limited anesthesia and operative supplies, and the lack of recovery room time. Although both costs are high, there is still a significant savings performing the probing under propofol sedation. A disadvantage to the use of intravenous propofol sedation is the requirement of an anesthesiologist who feels comfortable placing an intravenous line in a conscious infant and administering propofol. At Schneider Children’s Hospital, one of the authors (C.M.) exclusively administers analgesics and sedatives without intubation or inhalational anesthetics for minimally invasive procedures or tests for which a child cannot cooperate such as probing of the nasolacrimal duct, endoscopy, lumbar puncture, cardiac catheterization, magnetic resonance imaging, electroencephalograms, and many other tests. Only a children’s hospital or a very large hospital can financially support a full-time anesthesiologist for sedation of children for various procedures or tests. Another disadvantage with intravenous propofol sedation is that verification of patency of the nasolacrimal duct is not possible in this setting. Irrigation of the nasolacrimal duct was avoided to decrease the risk of laryngospasm. Attempts at verification with “metal on metal contact” under the inferior turbinate caused the patient too much discomfort even with propofol sedation. Although we only discuss the use of intravenous propofol sedation for probing of the nasolacrimal duct, our ophthalmology department has used intravenous propofol sedation for ocular examinations under anesthesia, removal of corneal sutures and foreign bodies, and laser treatment of traumatic retinal tears. Intravenous propofol allows for sedation and amnesia; however, it does not provide adequate analgesia and would not be useful if the procedure caused pain and required no movement from the patient (eg, subtenons injection). Intravenous propofol is not an ideal sedative to use to measure intraocular pressure, since it can cause a significant decrease in intraocular pressure ranging from 27% to 53%.17 In summary, late probing of the nasolacrimal duct under intravenous propofol sedation is effective, is a shorter procedure, and is less expensive compared with late probing under general inhalational anesthesia. Although the cost per patient of late probing under intravenous propofol sedation is greater compared with early officebased probing, the relative cost or the total cost to the
Journal of AAPOS Volume 4 Number 3 June 2000
182 Movaghar et al health care system may be less if probing is delayed until 1 year of age, because early probing under restraint subjects many children to a procedure for a problem that may spontaneously resolve by 1 year of age. We wish to thank Cindy Albarracin, RN, for her help with this project.
11.
12.
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