Propofol and fentanyl sedation for laser treatment of retinopathy of prematurity to avoid intubation

Respiratory Complications in Infants with Retinopathy of Prematurity (ROP) Requiring Laser Photocoagulation

OBJECTIVE

The objective of this paper was to describe peri-procedural events and complications of infants requiring laser photocoagulation for retinopathy of prematurity (ROP) in a level IV neonatal intensive care unit.

STUDY DESIGN

A retrospective chart review was performed of neonates requiring ROP exams from January 2017 to August 2020. Baseline maternal and neonatal characteristics, ROP exam findings, and associated treatment were analyzed. Group characteristics were compared based on the need for laser photocoagulation. Subgroup analysis of the laser group including respiratory outcomes, cardiorespiratory index (CRI) scores, and pain scores was also performed.

RESULTS

Neonatal and maternal characteristics in the laser (n = 27) and non-laser (n = 172) groups were assessed. Of the 81.5% (22/27) that required re-intubation for laser, 36% (8/22) had >1 intubation and 18% (4/22) had >1 extubation attempt. The average duration of intubation following laser was 2.46 ± 7.13 days, with 40% (9/22) needing peri-extubation steroids and 18% (4/22) racemic epinephrine to facilitate extubation. Mean total respiratory support time post-laser was 8.65 ± 15.23 days. Mean neonatal pain, agitation, and sedation scores after laser were zero immediately after the procedure, 0.09 ± 0.33 at 12 hours, 0.11 ± 0.47 at 24 hours, and 0.11 ± 0.51 at 48 hours. The mean CRI scores were 1 ± 0 immediately after the procedure, 1.17 ± 0.4 at 12 hours, 1.41 ± 0.20 at 24 hours, and 1 ± 0 at 48 hours.

CONCLUSION

Nearly all infants undergoing laser photocoagulation for ROP in our cohort required intubation and continued respiratory support. Despite stability during the procedure, complications from intubation were common.

KEY POINTS

· Routine intubation for laser is associated with complications.. · Need for post-procedural respiratory support is common.. · Avoiding intubation may mitigate these neonatal complications..

Twelve-year outcomes of bedside laser photocoagulation for severe retinopathy of prematurity

Purpose

The purpose of this study is to evaluate the 12-year outcomes of bedside laser photocoagulation (LP) for severe retinopathy of prematurity (ROP) under sedation combined with ocular surface anesthesia in neonatal intensive care units (NICU).

Design

The study is a retrospective case series.

Methods

Infants treated with bedside LP for severe ROP from April 2009 to September 2021 were included. All LP treatments were performed under sedation and surface anesthesia at the bedside in NICU. Data were recorded for clinical and demographic characteristics, total laser spots, duration of treatment, proportion of total regression of ROP, proportion of recurrence, and adverse events.

Results

A total of 364 infants (715 eyes) were included, with a mean gestational age of 28.6 ± 2.4 weeks (range: 22.6-36.6 weeks) and a mean birth weight of 1,156.0 ± 339.0 g (range: 480-2,200 g). The mean number of laser spots was 832 ± 469, and the mean duration of treatment was 23.5 ± 5.3 min per eye. Of all the eyes, 98.3% responded to LP with complete regression of ROP. ROP recurred in 15 (2.1%) eyes after the initial LP. Additional LP was performed in seven (1.0%) eyes. No patient exhibited mistaken LP of other ocular tissues, and there were no serious ocular adverse effects. None of them needed endotracheal intubation.

Conclusions

Bedside LP treatment is effective and safe for premature infants with severe ROP under sedation and surface anesthesia in NICU, especially for infants whose general condition is unstable and not suitable for transport.

Safety profile of anesthetic modalities during laser treatment for retinopathy of prematurity: a systematic review

OBJECTIVE

To determine the anesthetic approach with the least adverse events and better cardiorespiratory stability profile, used in infants undergoing laser photocoagulation for retinopathy of prematurity.

STUDY DESIGN

A systematic review was conducted. PubMed, Scopus, and Cochrane Library were searched until 27th October 2021. Reference lists of relevant studies, and abstract books of international annual meetings of pediatric Οphthalmology for the years 2020 and 2021 were also looked at, as well as Clinical trials registry ( https://clinicaltrials.gov/ ).

RESULT

Overall 18 primary studies (3 randomized controlled trials, 3 cohorts, 12 case series) were included, investigating different anesthetic modalities. Cardiopulmonary instability was more common, and hypothermia was less common in the sedation groups of pentazocine/midazolam and fentanyl/midazolam, compared to the general anesthesia group of air/oxygen/sevoflurane (AOS). Cardiorespiratory instability was also more common in sedation with propofol/ketamine compared to general anesthesia with AOS, while postoperative mechanical ventilation was more frequently needed in the latter. Αpnea, need for supplemental oxygen and cardiorespiratory instability was more frequent in infants receiving fentanyl as opposed to ketamine. Fentanyl compared to morphine presented no differences in safety parameters. Finally, topical anesthesia showed the greatest instability with a higher mean postoperative cardiorespiratory index, compared to both sedation and general anesthesia. Episodes of life-threatening events were reported after topical anesthesia, while hypothermia and oliguria presented less often after topical, compared to general anesthesia and sedation.

CONCLUSION

Significant heterogeneity among studies precludes direct comparisons and generalizability of the results. No specific anesthetic modality for treatment of ROP with laser photocoagulation was shown to be superior in terms of safety. Well-designed studies are required to establish the optimal anesthetic approach, considering that laser photocoagulation still remains one of the main therapeutic modalities for ROP.

The Male to Female Ratio in Treatment-Warranted Retinopathy of Prematurity: A Systematic Review and Meta-analysis

Importance

Literature and anecdotal evidence suggest a relationship between male sex and retinopathy of prematurity (ROP). It is not known whether a difference, if present, is sex-related pathophysiologic predisposition or sex difference in meeting ROP screening criteria.

Objective

To evaluate the association of sex with the development of treatment-warranted ROP.

Data Sources

PubMed, Embase, and Web of Science databases were searched from 2000 to 2022. The search strategy used keywords including retinopathy of prematurity or ROP or retrolental fibroplasia and treatment or anti-VEGF or bevacizumab or ranibizumab or aflibercept or conbercept or laser or cryotherapy and gender or sex or male or female and medical subject headings terms.

Study Selection

All studies reporting on treatment with anti-vascular endothelial growth factor, laser photocoagulation, and/or cryotherapy for ROP were identified. Studies reporting sex distribution in the treatment group were included in the meta-analysis. Exclusion criteria included case reports, case series of fewer than 10 treated patients, systematic reviews, conference abstracts, letters to the editor, animal studies, and non-English records.

Data Extraction and Synthesis

Two reviewers independently screened and extracted the data following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The proportions of treated male and female infants were combined using random-effects meta-analysis.

Main Outcomes and Measures

Numbers and percentages of male and female infants treated for ROP.

Results

Of 11 368 identified studies, 316 met inclusion criteria, yielding a total of 31 026 treated patients. A higher percentage of male infants were treated for ROP (55% [95% CI, 0.54%-0.55%]), with low heterogeneity between studies (I2 = 34%; P < .001). Thirty-eight studies reported sex distribution in the screened population (170 053 patients; 92 612 [53%] male vs 77 441 [47%] female). There was no significant difference in the odds of receiving treatment between screened male and female infants (pooled odds ratio, 1.04 [95% CI, 0.91-1.18]; P = .67).

Conclusions and Relevance

More male infants are treated for ROP than female infants. This could be due to a known relative pathophysiological fragility of preterm male infants in addition to a difference in ROP screening rates, with more male infants meeting the criteria than female infants. These findings have implications for future studies and may prompt more careful clinical monitoring of male neonates.

Stimulating and maintaining spontaneous breathing during transition of preterm infants

Most preterm infants breathe at birth, but need additional respiratory support due to immaturity of the lung and respiratory control mechanisms. To avoid lung injury, the focus of respiratory support has shifted from invasive towards non-invasive ventilation. However, applying effective non-invasive ventilation is difficult due to mask leak and airway obstruction. The larynx has been overlooked as one of the causes for obstruction, preventing face mask ventilation from inflating the lung. The larynx remains mostly closed at birth, only opening briefly during a spontaneous breath. Stimulating and supporting spontaneous breathing could enhance the success of non-invasive ventilation by ensuring that the larynx remains open. Maintaining adequate spontaneous breathing and thereby reducing the need for invasive ventilation is not only important directly after birth, but also in the first hours after admission to the NICU. Respiratory distress syndrome is an important cause of respiratory failure. Traditionally, treatment of RDS required intubation and mechanical ventilation to administer exogenous surfactant. However, new ways have been implemented to administer surfactant and preserve spontaneous breathing while maintaining non-invasive support. In this narrative review we aim to describe interventions focused on stimulation and maintenance of spontaneous breathing of preterm infants in the first hours after birth.

Anesthesia management of laser photocoagulation for retinopathy of prematurity. A retrospective review of perioperative adverse events

AIMS

The aim of this study was to report the incidence of perioperative adverse events occurring in infants undergoing diode laser photocoagulation of retinopathy of prematurity and to identify clinical risk factors that may affect the incidence.

METHODS

This was a retrospective study of anesthetic and medical records of premature infants who were treated in the neonatal intensive care unit or an operating theater with laser photocoagulation in our institution between January 2014 and December 2019. Infants less than 38 weeks post-menstrual age or less than 2000 grams were considered high risk for complications. Electronic medical records were evaluated for clinical and demographic characteristics, comorbidities, and perioperative complications of anesthesia.

RESULTS

Sixty-one infants (39 males, 22 females) underwent 72 laser treatments. The mean gestational age was 25.3 weeks (SD 1.6), and mean birth weight was 730 grams (SD 202). At treatment, the mean postmenstrual age was 37.5 weeks (SD 2.7) and weight was 2320 g (SD 610). Laser therapy was performed in an operating theater in 66 procedures (91.7%) and in the neonatal unit in 6 cases (8.3%). Twenty-nine (40.3%) laser surgeries occurred outside normal week-day daytime operating hours. Intraoperative hypotension occurred in 12 procedures (16.7%) but was not significantly different in high-risk infants (16.1% vs 16.7% OR 0.94 P = .94) or in procedures performed in-hours (16.3% vs 17.2% OR 0.93 P = .91). Post-extubation apnea occurred in 21 procedures (29%) but was not significantly different in high-risk infants (29.0% vs 27.3% OR 0.98 P = .34) or in procedures performed in-hours (27.9% vs 31.1% OR 0.86 P = .77). Infants remained intubated at the end of the procedure in 58 (80.5%) cases and 29 (40.3%) remained ventilated more than 24 hours after the procedure.

CONCLUSION

The incidence of perioperative adverse events was not associated with patient's age, current weight, timing, or location of the procedure. Extubating infants at the end of the procedure is however associated with a high rate of apneas and bradycardia, and consideration should be given to keeping low weight infants undergoing prolonged procedures out-of-hours intubated.

A Comparison of Respiratory Outcomes after Treating Retinopathy of Prematurity with Laser Photocoagulation or Intravitreal Bevacizumab

PURPOSE

To compare respiratory outcomes after treatment of retinopathy of prematurity (ROP) between infants treated with laser therapy under general anesthesia and infants treated with intravitreal bevacizumab under bedside sedation.

DESIGN

Retrospective cohort study.

PARTICIPANTS

One hundred thirty-eight consecutive infants treated for ROP from September 2010 through September 2018 at 1 institution.

METHODS

Retrospective medical, procedural, and ophthalmologic data were collected, including preprocedure (baseline) and postprocedure (24 hours, 48 hours, 7 days, and 28 days) respiratory status, birth weight, gestational age, gender, ROP treatment method, postmenstrual age at treatment, and coincident nonocular procedures during anesthesia. Respiratory outcomes at 48 hours were compared between infants treated with laser therapy under general anesthesia and infants treated with intravitreal bevacizumab under local sedation using multivariate logistic regression analysis to control for potentially confounding factors.

MAIN OUTCOME MEASURES

Proportion of infants who had returned to their respiratory baseline by 48 hours after ROP treatment.

RESULTS

Return to respiratory baseline was significantly less common among 119 infants initially treated with laser therapy compared with 19 infants initially treated with bevacizumab at 24 hours (40% vs. 74%; P = 0.0115), 48 hours (53% vs. 79%; P = 0.0453), and 7 days (79% vs. 100%; P = 0.0242). In a multivariate logistic regression analysis, infants treated with laser therapy were less likely to return to respiratory baseline at 48 hours (odds ratio, 0.14; 95% confidence interval, 0.04-0.54). At 28 days, no difference was found between groups (laser, 97%; bevacizumab, 100%; P > 0.99).

CONCLUSIONS

Infants treated with intravitreal bevacizumab using bedside sedation returned to their preprocedure respiratory baseline faster than infants treated with laser under general anesthesia, with the differences persisting at least to 7 days or more after the procedure.

Propofol use in newborns and children: is it safe? A systematic review

OBJECTIVES

To determine the main indications and assess the most common adverse events with the administration of hypnotic propofol in most pediatric clinical scenarios.

SOURCES

A systematic review of PubMed, SciELO, Cochrane, and EMBASE was performed, using filters such as a maximum of five years post-publication, and/or references or articles of importance, with emphasis on clinical trials using propofol. All articles of major relevance were blind-reviewed by both authors according to the PRISMA statement, looking for possible bias and limitations or the quality of the articles.

SUMMARY OF THE FINDINGS

Through the search criterion applied, 417 articles were found, and their abstracts evaluated. A total of 69 papers were thoroughly studied. Articles about propofol use in children are increasing, including in neonates, with the majority being cohort studies and clinical trials in two main scenarios: upper digestive endoscopy and magnetic resonance imaging. A huge list of adverse events has been published, but most articles considered them of low risk.

CONCLUSIONS

Propofol is a hypnotic drug with a safe profile of efficacy and adverse events. Indeed, when administered by non-anesthesiologists, quick access to emergency care must be provided, especially in airway events. The use of propofol in other scenarios must be better studied, aiming to reduce the limitations of its administration by general pediatricians.

Propofol Formulation Affects Myocardial Function in Newborn Infants

This study aimed to evaluate the effects of propofol in diluted and undiluted formulations on cardiac function in infants. Infants > 30 days received propofol sedation for central line insertion. Cases were divided into two groups: those who received undiluted 1% propofol (P1%); and those who received a diluted formulation (Pd) of equal volumes propofol 1% and 0.9% NaCl. Echocardiograms were performed pre (t₀)-, immediately post (t₁)-, and 1-h post (t₂) propofol administration. Myocardial deformation was assessed with tissue Doppler imaging (TDI) analysis and peak longitudinal strain (LS). 18 cases were included: nine (50%) P1% and nine (50%) Pd. In the P1% group, TDI velocities and LS were significantly reduced at t₁ and t₂. In the Pd Group, only TDI velocities in the left ventricle were reduced at t₁, but not at t₂. Dilution of propofol may minimize myocardial dysfunction while maintaining adequate sedation in infants. Further comparative studies are needed to investigate the safety and efficacy of this approach.