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Sneezing Reflex Associated With Intravenous Sedation and Periocular Anesthetic Injection
CORRESPONDENCE Sneezing Reflex Associated With Intravenous Sedation and Periocular Anesthetic Injection
2. Tao J, Nunery W, Kresovsky S, Mote T, Lister L. The efficacy of fentanyl or alfentanil in suppressing reflex sneezing after propofol sedation and periocular injection. Ophthal Plast Reconstr Surg 2008. Forthcoming.
EDITOR: AHN AND ASSOCIATES1 REVISIT THE ASSOCIATION BE-
tween sneezing during periocular injections of anesthetic and intravenous (IV) sedation. The authors do well raising awareness of a phenomenon that is highly clinically relevant, since unexpected patient movement with a needle near the eye can lead to catastrophic outcomes. They retrospectively compared patients undergoing oculoplastic procedures with local anesthesia alone vs those receiving local injections with adjunctive IV medications. A statistically significant difference is reported; none of the patients given only periocular anesthetic injections sneezed. However, apart from selected data in the patients who sneezed, they report few particulars of the IV medications utilized. Timing, dosage, and other regimen specifics are not delineated and no information is provided on the IV medications administered to the patients who did not sneeze, ie, the other 362 subjects in the “test” group. This information may be relevant since the assorted IV agents and the various combination regimens may be unequal. For instance, sneezing has been more strongly associated with the sedative hypnotic, propofol, and not necessarily with other sedatives like midazolam. In addition, we demonstrated, in a prospective investigation, that an opioid (fentanyl or alfentanyl), given minutes prior to propofol, eliminated the sneeze reflex with periocular injections.2 We also found that the combination of midazolam with propofol seemed to increase the risk for sneezing, but this did not reach statistical significance. Stratification for the various IV medication regimens given in Ahn and associates’ study may provide added insights. Differentiating these parameters when considering sneezing during periocular injections may further elucidate the best ways to improve patient comfort and safety. JEREMIAH P. TAO
Irvine, California
REFERENCES
1. Ahn ES, Mills DM, Meyer DR, Stasior GO. Sneezing reflex associated with intravenous sedation and periocular anesthetic injection. Am J Ophthalmol 2008;146:31–35. 0002-9394/09/$36.00
©
2009 BY
REPLY TAO AND ASSOCIATES COMMENT ON THE INFLUENCE
certain intravenous (IV) anesthetic agents impart on reflex sneezing, noting that certain agents like propofol have a stronger association with the phenomenon than other sedatives like midazolam. In our study, propofol also seemed to encourage sneezing more than other agents, as all of those found to sneeze had received this agent.1 Yet, we did not specifically attempt to implicate propofol or any other sedative as the sole inducer of sneezing. We hoped instead only to elucidate an esoteric reaction and bring it to awareness, using observations we had noted from our procedures. Granted, our study was limited, as mentioned in our article, by the lack of standardized timing and dosage of IV medication given, as well as other regimen specifics. Although no time interval was strictly adhered to, we proceeded with the common practice of administering periocular anesthetic injections only after patients were found to be unresponsive to voice and eyelash reflexes. The amount and type of IV sedation given was also dependent on the anesthesia staff present on the day of the procedure as well. These factors deserve analysis in a more structured study, but from our results we clearly showed that there was an association between anesthetic injections and IV sedation, because those receiving anesthetic injections only, without IV sedations, did not sneeze. For those who did not sneeze despite receiving IV sedation, the agents used were more often than not common and popular sedatives such as propofol and midazolam. Further analysis into the anesthetics used would be helpful in differentiating and implicating one agent vs another, but again our ultimate aim was highlighting a potential harmful phenomenon. Tao and associates raise an interesting point regarding the potential of opioids like fentanyl in suppressing sneezing, and we hope future studies will be able to better identify which particular IV sedatives require greater surveillance to enhance patient safety, as well as methods to suppress this reflex as well.
ELSEVIER INC. ALL
ERIC S. AHN
Slingerlands, New York RIGHTS RESERVED.
183
2. Tao J, Nunery W, Kresovsky S, Mote T, Lister L. The efficacy of fentanyl or alfentanil in suppressing reflex sneezing after propofol sedation and periocular injection. Ophthal Plast Reconstr Surg 2008. Forthcoming.
EDITOR: AHN AND ASSOCIATES1 REVISIT THE ASSOCIATION BE-
tween sneezing during periocular injections of anesthetic and intravenous (IV) sedation. The authors do well raising awareness of a phenomenon that is highly clinically relevant, since unexpected patient movement with a needle near the eye can lead to catastrophic outcomes. They retrospectively compared patients undergoing oculoplastic procedures with local anesthesia alone vs those receiving local injections with adjunctive IV medications. A statistically significant difference is reported; none of the patients given only periocular anesthetic injections sneezed. However, apart from selected data in the patients who sneezed, they report few particulars of the IV medications utilized. Timing, dosage, and other regimen specifics are not delineated and no information is provided on the IV medications administered to the patients who did not sneeze, ie, the other 362 subjects in the “test” group. This information may be relevant since the assorted IV agents and the various combination regimens may be unequal. For instance, sneezing has been more strongly associated with the sedative hypnotic, propofol, and not necessarily with other sedatives like midazolam. In addition, we demonstrated, in a prospective investigation, that an opioid (fentanyl or alfentanyl), given minutes prior to propofol, eliminated the sneeze reflex with periocular injections.2 We also found that the combination of midazolam with propofol seemed to increase the risk for sneezing, but this did not reach statistical significance. Stratification for the various IV medication regimens given in Ahn and associates’ study may provide added insights. Differentiating these parameters when considering sneezing during periocular injections may further elucidate the best ways to improve patient comfort and safety. JEREMIAH P. TAO
Irvine, California
REFERENCES
1. Ahn ES, Mills DM, Meyer DR, Stasior GO. Sneezing reflex associated with intravenous sedation and periocular anesthetic injection. Am J Ophthalmol 2008;146:31–35. 0002-9394/09/$36.00
©
2009 BY
REPLY TAO AND ASSOCIATES COMMENT ON THE INFLUENCE
certain intravenous (IV) anesthetic agents impart on reflex sneezing, noting that certain agents like propofol have a stronger association with the phenomenon than other sedatives like midazolam. In our study, propofol also seemed to encourage sneezing more than other agents, as all of those found to sneeze had received this agent.1 Yet, we did not specifically attempt to implicate propofol or any other sedative as the sole inducer of sneezing. We hoped instead only to elucidate an esoteric reaction and bring it to awareness, using observations we had noted from our procedures. Granted, our study was limited, as mentioned in our article, by the lack of standardized timing and dosage of IV medication given, as well as other regimen specifics. Although no time interval was strictly adhered to, we proceeded with the common practice of administering periocular anesthetic injections only after patients were found to be unresponsive to voice and eyelash reflexes. The amount and type of IV sedation given was also dependent on the anesthesia staff present on the day of the procedure as well. These factors deserve analysis in a more structured study, but from our results we clearly showed that there was an association between anesthetic injections and IV sedation, because those receiving anesthetic injections only, without IV sedations, did not sneeze. For those who did not sneeze despite receiving IV sedation, the agents used were more often than not common and popular sedatives such as propofol and midazolam. Further analysis into the anesthetics used would be helpful in differentiating and implicating one agent vs another, but again our ultimate aim was highlighting a potential harmful phenomenon. Tao and associates raise an interesting point regarding the potential of opioids like fentanyl in suppressing sneezing, and we hope future studies will be able to better identify which particular IV sedatives require greater surveillance to enhance patient safety, as well as methods to suppress this reflex as well.
ELSEVIER INC. ALL
ERIC S. AHN
Slingerlands, New York RIGHTS RESERVED.
183