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Moradi Farsani D, Shakerinia SE. Comparing Effectiveness and Safety of Intravenous Atropine with Topical Tetracaine in Preventing and Relieving Oculocardiac Reflex in Patients Undergoing Strabismus Surgery: A Randomized Clinical Trial. Adv Biomed Res 2024; 13:8. [PMID: 38525386 PMCID: PMC10958729 DOI: 10.4103/abr.abr_167_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 08/24/2023] [Accepted: 08/30/2023] [Indexed: 03/26/2024] Open
Abstract
Background Oculocardiac reflex (OCR) is one of the serious complications following surgical therapeutic procedures for strabismus. Various medications have been tested to prevent or mitigate this complication. We aimed to compare the effect of intravenous atropine and topical tetracaine on the incidence and severity of OCR in strabismus surgery. Materials and Methods In this triple-blind randomized clinical trial study, 120 patients who were candidates for strabismus surgery were randomly assigned to receive intravenous atropine, topical tetracaine, or artificial tears as the control. The incidence of OCR and its severity along with the changes in hemodynamic conditions were compared across the groups. Results The incidence rate of OCR in the groups receiving atropine, tetracaine, and the control was found to be 17.5%, 25.0%, and 32.5% in the releasing phase without any difference, respectively (P = 0.303); however, it was 2.5%, 7.5%, and 25.0%, respectively, in the cutting phase, indicating a lower rate in the group receiving tetracaine (P = 0.004). Similarly, there was no difference in the severity of OCR across the three study groups in the releasing phase (P = 0.666); however, in the cutting phase, OCR was revealed to be milder in the group receiving atropine as compared to other groups (P = 0.033). Prescribing atropine led to higher mean systolic blood pressure and mean arterial pressure during surgery. Conclusion The injection of atropine can effectively reduce the incidence of OCR during strabismus surgery and reduce its severity if this reflex occurs.
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Affiliation(s)
- Darioush Moradi Farsani
- Department of Anesthesia and Critical Care, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Seyed Ehsan Shakerinia
- Department of Anesthesia and Critical Care, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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Juan I, Lin M, Greenberg M, Robbins SL. Surgical and anesthetic influences of the oculocardiac reflex in adults and children during strabismus surgery. Surv Ophthalmol 2023; 68:977-984. [PMID: 37116545 DOI: 10.1016/j.survophthal.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 04/23/2023] [Accepted: 04/24/2023] [Indexed: 04/30/2023]
Abstract
One of the most common untoward occurrences during strabismus surgery at all ages is the oculocardiac reflex. Although typically easily treated, the sudden bradycardia or cardiac arrest may add a few gray hairs to ophthalmologists and anesthesiologists alike as it can be potentially fatal. This updated review of the literature and novel detailed treatment algorithm may prevent patient morbidity and mortality through proper recognition of at-risk patients and rapid treatment through proper communication between surgical and anesthesia physicians/providers.
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Affiliation(s)
- Ilona Juan
- Department of Anesthesiology, University of California San Diego, La Jolla, CA, USA
| | - Mark Lin
- Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, CA, USA
| | - Mark Greenberg
- Department of Anesthesiology, University of California San Diego, La Jolla, CA, USA
| | - Shira L Robbins
- Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, CA, USA.
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Hydroxyzine Dihydrochloride Premedication Is a Necessity for Pediatric Patients Undergoing Strabismus Surgery: An Observational Prospective Clinical Trial. J Ophthalmol 2022; 2022:4137144. [PMID: 36189149 PMCID: PMC9519320 DOI: 10.1155/2022/4137144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 08/26/2022] [Accepted: 09/02/2022] [Indexed: 11/24/2022] Open
Abstract
Objective In this single-blind, observational prospective clinical trial, we aimed to determine and compare the effects of premedication with hydroxyzine plus midazolam and midazolam alone on the incidence of oculocardiac reflex (OCR). Methods Forty-five patients were divided into three groups. Group M received 0.5 mg/kg midazolam alone, Group H received 0.5 mg/kg hydroxyzine plus 0.5 mg/kg midazolam, and Group HM received 1 mg/kg hydroxyzine plus 0.5 mg/kg midazolam. The Ramsay Sedation Scale (RSS), the heart rates (HR1: after induction of anesthesia; HR2: before retraction of orbital muscle; and HR3: right after retraction of orbital muscle), the muscles with OCR, and the incidence of OCR (20% decrease of the HR right after the traction) were recorded and compared between the three groups. Results The mean HR1, HR2, and HR3 values were significantly increased (p=0.002, p < 0.001, p < 0.001) and the incidence of OCR (p=0.004) was significantly decreased in Group H and in Group HM (for all, p < 0.01) compared to Group M. The most common orbital muscle in which OCR occurred was the rectus medialis. Conclusion Premedication with a combination of 0.5 or 1 mg hydroxyzine with 0.5 mg midazolam significantly reduced the incidence of OCR compared to premedication with midazolam alone. This study was registered on https://clinicaltrials.gov/ with number NCT03806270.
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Abdeldayem O, Elsherbiny S. A comparison between the effects of propofol and sevoflurane in pediatric strabismus surgery on the quality and depth of anesthesia. Anesth Essays Res 2021; 15:257-262. [PMID: 35320953 PMCID: PMC8936868 DOI: 10.4103/aer.aer_93_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 10/30/2020] [Accepted: 11/19/2020] [Indexed: 12/02/2022] Open
Abstract
Background: Strabismus surgery may be associated with several undesirable complications as increased incidence of the oculocardiac reflex (OCR), hemodynamic changes, emergency agitation (EA), postoperative pain, nausea, and vomiting. Previous studies suggested that deeper anesthesia monitored by bispectral index (BIS) protects against OCR. This study aims to evaluate the effect of the type of anesthesia on the quality of anesthesia in pediatric patients. Patients and Methods: One hundred American Society of Anesthesiologists physical status classes I and II pediatric patients, aged between 3 and 6 years old of both genders, who were subjected to strabismus surgery under general anesthesia were enrolled in this study. Patients were randomized into two equal groups (each = 50); in the first group, anesthesia was induced and maintained with sevoflurane (Group S), and in the second group, anesthesia was induced and maintained with propofol (Group P). Hemodynamics and BIS were monitored, and OCR and the need for atropine were recorded. Furthermore, EA using the Cravero scale was recorded. Results: The propofol group showed a higher incidence of OCR while the sevoflurane group had a higher incidence of postoperative agitation, pain, nausea, and vomiting, without statistically significant differences regarding hemodynamics. Conclusion: Although sevoflurane anesthesia may be superior to propofol in ameliorating OCR, it has been associated with an increased incidence of postoperative complications.
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Chua AW, Chua MJ, Leung H, Kam PC. Anaesthetic considerations for strabismus surgery in children and adults. Anaesth Intensive Care 2020; 48:277-288. [PMID: 32777929 DOI: 10.1177/0310057x20937710] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Strabismus correction surgery is the most common eye operation in children. Adults have approximately a 4% lifetime risk of developing strabismus. Current treatment options include pharmacological injection of botulinum toxin or bupivacaine, conventional corrective surgery, adjustable suture surgery and minimally invasive surgery. Repeated surgery is common as each operation has a 60%-80% chance of successful correction. The benefits of early surgical correction in large-angle strabismus in children outweigh the risks of anaesthesia. General anaesthesia is suitable for patients of all age groups, for complicated or repeated surgery, and bilateral eye procedures. Regional ophthalmic block reduces the incidence of oculocardiac reflex and emergence agitation, and provides postoperative analgesia, but requires a cooperative patient as many experience discomfort. Topical anaesthesia has been used in pharmacological injection, minimally invasive surgery, uncomplicated conventional strabismus surgery and some adjustable suture strabismus surgery. Its use, however, is only limited to cooperative adult patients. Prophylactic antiemesis with both ondansetron and dexamethasone is recommended, especially for children. A multimodal analgesia approach, including paracetamol, intravenous non-steroidal anti-inflammatory drugs, topical local anaesthetic and minimal opioid usage, is recommended for postoperative analgesia, while a supplementary regional ophthalmic block is at the discretion of the team.
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Affiliation(s)
- Alfred Wy Chua
- Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, Australia
| | - Matthew J Chua
- Department of Intensive Care Medicine, Nepean Hospital, Sydney, Australia
| | - Harry Leung
- Department of Ophthalmology, Sydney Children's Hospital, Sydney, Australia
| | - Peter Ca Kam
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
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The Effect of Depth of Anesthesia on Hemodynamic Changes Induced by Therapeutic Compression of the Trigeminal Ganglion. J Neurosurg Anesthesiol 2019; 32:344-348. [DOI: 10.1097/ana.0000000000000612] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Rahimi Varposhti M, Moradi Farsani D, Ghadimi K, Asadi M. Reduction of oculocardiac reflex with Tetracaine eye drop in strabismus surgery. Strabismus 2019; 27:1-5. [PMID: 30831045 DOI: 10.1080/09273972.2018.1561732] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Recently, to reduce the incidence of oculocardiac reflex (OCR) in strabismus surgery, retrobulbar block and anticholinergic drugs or local anesthesia are also used. The present study evaluated the effects of Tetracaine eye drop as a topical nerve blocker on OCR during strabismus surgery. METHODS AND MATERIALS In this randomized trial, 70 strabismus surgery candidates were randomly divided into placebo or synthetic teardrop (E) and Tetracaine eye drop (T) groups, so 3 drops of each solution were dropped in four directions of patients' eye immediately after applying anesthesia and before surgery. The incidence and severity of OCR during the stages of muscle release and incision (cutting), hemodynamic changes, the required time for OCR recovery and atropine dose were assessed. RESULTS OCR was more seen in release phase compared to cutting phase. There were no significant differences between two group regarding the incidence and severity of OCR in the release phase (p > 0.05), but the incidence and severity of OCR in the cutting phase was more in group E than group T (p = 0.02, for both). The duration of OCR improvement (p-value = 0.74) and Atropine consumption (p-value = 0.92) did not differ between the groups. CONCLUSION Tetracaine eye drop only reduces the incidence and severity of OCR during the incision stage of strabismus surgery.
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Affiliation(s)
- Mojtaba Rahimi Varposhti
- a Department of Anesthesiology, Faculty of Medicine , Isfahan University of Medical Sciences , Isfahan
| | - Darioush Moradi Farsani
- a Department of Anesthesiology, Faculty of Medicine , Isfahan University of Medical Sciences , Isfahan
| | - Keyvan Ghadimi
- b School of medicine , Isfahan University of Medical Sciences , Isfahan
| | - Mehrdad Asadi
- b School of medicine , Isfahan University of Medical Sciences , Isfahan
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Ducloyer JB, Couret C, Magne C, Lejus-Bourdeau C, Weber M, Le Meur G, Lebranchu P. Prospective evaluation of anesthetic protocols during pediatric ophthalmic surgery. Eur J Ophthalmol 2018; 29:606-614. [PMID: 30280604 DOI: 10.1177/1120672118804798] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To date, no protocol of anesthesia for pediatric ophthalmic surgery is unanimously recognized. The primary anesthetic risks are associated with strabismus surgery, including oculocardiac reflex, postoperative nausea and vomiting, and postoperative pain. METHODS This was a prospective, monocentric, observational study conducted in a tertiary pediatric ophthalmic unit. Our anesthetic protocol for strabismus surgery included postoperative nausea and vomiting prevention using dexamethasone and ondansetron. No drug-based prevention of oculocardiac reflex or local/locoregional anesthesia was employed. RESULTS A total of 106 pediatric ophthalmic surgeries completed between November 2015 and May 2016 were analyzed. The mean patient age was 4.4 (range: 0.2-7.3, standard deviation: 2.4) years. Ambulatory rate was 90%. Oculocardiac reflex incidence was 65% during strabismus surgery (34/52), 50% during congenital cataract surgery (4/8), 33% during intramuscular injection of botulinum toxin (1/3), and 0% during other procedures. No asystole occurred. Postoperative nausea and vomiting incidence was 9.6% after strabismus surgery (5/52) and 0% following the other procedures. One child was hospitalized for one night because of persistent postoperative nausea and vomiting. Postoperative pain generally occurred early on in the recovery room and was quickly controlled. Its incidence was higher in patients who underwent strabismus surgery (27%) than in those who underwent other procedures (9%). CONCLUSION Morbidity associated with ophthalmic pediatric surgery is low and predominantly associated with strabismus surgery. The benefit-risk ratio and cost-effectiveness of oculocardiac reflex prevention should be questioned. Our postoperative nausea and vomiting rate is low, thanks to the use of a well-managed multimodal strategy. Early postoperative pain is usually well-treated but could probably be more effectively prevented.
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Affiliation(s)
| | - Chloé Couret
- Department of Ophthalmology, University Hospital of Nantes, Nantes, France
| | - Cécile Magne
- Department of Anesthesiology and Surgical Intensive Care Médicine, University Hospital of Nantes, Nantes, France
| | - Corinne Lejus-Bourdeau
- Department of Anesthesiology and Surgical Intensive Care Médicine, University Hospital of Nantes, Nantes, France
| | - Michel Weber
- Department of Ophthalmology, University Hospital of Nantes, Nantes, France
| | - Guylène Le Meur
- Department of Ophthalmology, University Hospital of Nantes, Nantes, France
| | - Pierre Lebranchu
- Department of Ophthalmology, University Hospital of Nantes, Nantes, France
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Buchholz B, Kelly J, Bernatene EA, Méndez Diodati N, Gelpi RJ. Antagonistic and Synergistic Activation of Cardiovascular Vagal and Sympathetic Motor Outflows in Trigeminal Reflexes. Front Neurol 2017; 8:52. [PMID: 28270794 PMCID: PMC5318455 DOI: 10.3389/fneur.2017.00052] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 02/06/2017] [Indexed: 11/13/2022] Open
Abstract
The trigeminal nerve and heart are strongly related through somato-autonomic nervous reflexes that induce rapid changes in cardiovascular function. Several trigeminal reflexes have been described, but the diving and trigeminocardiac reflexes are the most studied. The heart is a target organ dually innervated by the sympathetic and parasympathetic systems. Thus, how cardiac function is regulated during the trigeminal reflexes is the result of the combination of an increased parasympathetic response and increased, decreased, or unaltered sympathetic activity. Various hemodynamic changes occur as a consequence of these alterations in autonomic tone. Often in the oxygen-conserving physiological reflexes such as the diving reflex, sympathetic/parasympathetic co-activation reduces the heart rate and either maintains or increases blood pressure. Conversely, in the trigeminocardiac reflex, bradycardia and hypotension due to parasympathetic activation and sympathetic inactivation tend to be observed. These sudden cardiac innervation disturbances may promote the generation of arrhythmias or myocardial ischemia during surgeries in the trigeminal territory. However, the function and mechanisms involved in the trigeminal reflexes remain to be fully elucidated. The current review provides a brief update and analysis of the features of these reflexes, with special focus on how the autonomic nervous system interacts with cardiovascular function.
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Affiliation(s)
- Bruno Buchholz
- Facultad de Medicina, Departamento de Patología, Instituto de Fisiopatología Cardiovascular (INFICA), Universidad de Buenos Aires, Buenos Aires, Argentina; Facultad de Medicina, Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Instituto de Bioquímica y Medicina Molecular (IBIMOL), Universidad de Buenos Aires, Buenos Aires, Argentina; Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Buenos Aires, Argentina
| | - Jazmín Kelly
- Facultad de Medicina, Departamento de Patología, Instituto de Fisiopatología Cardiovascular (INFICA), Universidad de Buenos Aires, Buenos Aires, Argentina; Facultad de Medicina, Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Instituto de Bioquímica y Medicina Molecular (IBIMOL), Universidad de Buenos Aires, Buenos Aires, Argentina; Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Buenos Aires, Argentina
| | - Eduardo A Bernatene
- Facultad de Medicina, Departamento de Patología, Instituto de Fisiopatología Cardiovascular (INFICA), Universidad de Buenos Aires, Buenos Aires, Argentina; Facultad de Medicina, Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Instituto de Bioquímica y Medicina Molecular (IBIMOL), Universidad de Buenos Aires, Buenos Aires, Argentina; Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Buenos Aires, Argentina
| | - Nahuel Méndez Diodati
- Facultad de Medicina, Departamento de Patología, Instituto de Fisiopatología Cardiovascular (INFICA), Universidad de Buenos Aires , Buenos Aires , Argentina
| | - Ricardo J Gelpi
- Facultad de Medicina, Departamento de Patología, Instituto de Fisiopatología Cardiovascular (INFICA), Universidad de Buenos Aires, Buenos Aires, Argentina; Facultad de Medicina, Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Instituto de Bioquímica y Medicina Molecular (IBIMOL), Universidad de Buenos Aires, Buenos Aires, Argentina; Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Buenos Aires, Argentina
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Aletaha M, Bagheri A, Roodneshin F, Mosallaei M, Yazdani S. Oculocardiac Reflex during Strabismus Surgery: Experience from a Tertiary Hospital. Strabismus 2016; 24:74-8. [DOI: 10.3109/09273972.2016.1170049] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Karaman T, Demir S, Dogru S, Şahin A, Tapar H, Karaman S, Kaya Z, Suren M, Arici S. The effect of anesthesia depth on the oculocardiac reflex in strabismus surgery. J Clin Monit Comput 2015; 30:889-893. [PMID: 26438656 DOI: 10.1007/s10877-015-9789-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 10/01/2015] [Indexed: 02/02/2023]
Abstract
The aim of this study was to investigate the effect of the bispectral index (BIS) guided depth of anesthesia to inhibition of the oculocardiac reflex (OCR) during pediatric strabismus surgery. Patients between the ages of 3 and 16 years who were scheduled for elective strabismus surgery were randomly assigned to two groups. In Group 1 (n: 32), the BIS values of the patients were maintained at <50; in Group 2 (n: 28), the BIS values of the patients were maintained at levels greater than or equal to 50 with 4-7 % desflurane in a 50 % O2-air mixture by titrating the concentration during the surgery. The heart rates, presence of dysrhythmia, anticholinergic drug usage and the type of the operated extra ocular muscle were recorded. The incidence of OCR was 25 % in Groups 1 and 64.3 % in Group 2, (p < 0.05). Moreover, the incidence of OCR in group 2 was higher in medial rectus (MR) traction (78.9 %) than in lateral rectus (LR) traction (33.3 %) (p = 0.035), with no significant difference in Group 1 between MR (21.1 %) and LR (26.7 %) tractions (p = 0.83). We found that the lower BIS values are associated with the lower incidence of OCR in pediatric patients undergoing strabismus surgery. And our findings confirmed that the deeper anesthesia has a protective effect against the OCR.
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Affiliation(s)
- Tugba Karaman
- Department of Anesthesiology and Reanimation, Gaziosmanpasa University School of Medicine, 60100, Tokat, Turkey.
| | - Selim Demir
- Department of Ophthalmology, Gaziosmanpasa University School of Medicine, Tokat, Turkey
| | - Serkan Dogru
- Department of Anesthesiology and Reanimation, Gaziosmanpasa University School of Medicine, 60100, Tokat, Turkey
| | - Aynur Şahin
- Department of Anesthesiology and Reanimation, Gaziosmanpasa University School of Medicine, 60100, Tokat, Turkey
| | - Hakan Tapar
- Department of Anesthesiology and Reanimation, Gaziosmanpasa University School of Medicine, 60100, Tokat, Turkey
| | - Serkan Karaman
- Department of Anesthesiology and Reanimation, Gaziosmanpasa University School of Medicine, 60100, Tokat, Turkey
| | - Ziya Kaya
- Department of Anesthesiology and Reanimation, Gaziosmanpasa University School of Medicine, 60100, Tokat, Turkey
| | - Mustafa Suren
- Department of Anesthesiology and Reanimation, Gaziosmanpasa University School of Medicine, 60100, Tokat, Turkey
| | - Semih Arici
- Department of Anesthesiology and Reanimation, Gaziosmanpasa University School of Medicine, 60100, Tokat, Turkey
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Cardiac dysrhythmias in pediatric patients during general anesthesia. J Clin Anesth 2014; 26:255-6. [DOI: 10.1016/j.jclinane.2014.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Revised: 04/11/2014] [Accepted: 04/15/2014] [Indexed: 11/21/2022]
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13
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Lai YH, Hsu HT, Wang HZ, Cheng KI, Wu KY. The oculocardiac reflex during strabismus surgery: its relationship to preoperative clinical eye findings and subsequent postoperative emesis. J AAPOS 2014; 18:151-5. [PMID: 24698612 DOI: 10.1016/j.jaapos.2013.11.024] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Revised: 11/02/2013] [Accepted: 11/26/2013] [Indexed: 10/25/2022]
Abstract
PURPOSE To compare the occurrence of significant bradycardia due to the oculocardiac reflex (OCR) during strabismus surgery and its relationship to preoperative clinical eye findings and subsequent development of postoperative emesis. METHODS The medical records of consecutive patients who underwent strabismus surgery August 2006 to June 2009 were retrospectively reviewed. OCR was defined as presence of dysrhythmia or a sudden heart rate decrease ≥ 20% after traction on the extraocular muscle. OCR incidence was compared between the first, second, and third (if any) extraocular muscles in patients who had multiple-muscle strabismus surgery and also between specific muscles (eg, medial rectus vs lateral rectus muscle). Associations with OCR were compared for different strabismus types. Vomiting was considered postoperative if it occurred before discharge of the patient at noon on the day following surgery. Risk factors for OCR and postoperative vomiting were evaluated by logistic regression analysis. RESULTS A total of 111 records were reviewed; 41 patients (37%) experienced OCR. Incidence of OCR and absence of OCR during traction of the first muscle were significantly associated with events during traction of the second (χ(2) = 36.681, P < 0.001) and third muscles (Fisher exact test, P = 0.030). The best predictors of OCR were the absence of fine stereopsis and a larger number of surgically treated muscles. Of the 111 patients, 30 (27%) who had postoperative vomiting, the best predictors were female sex and young age. CONCLUSIONS In our cohort, patients experiencing intraoperative OCR when the first extraocular muscle was manipulated during multiple-muscle strabismus surgery were likely to experience it again during traction of additional muscles. More severe postoperative vomiting was common in these patients. OCR was associated with the preoperative absence of fine stereopsis.
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Affiliation(s)
- Yu-Hung Lai
- Department of Ophthalmology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Ophthalmology, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Ophthalmology, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hsin-Tien Hsu
- School of Nursing, College of Nursing, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hwei-Zu Wang
- Department of Ophthalmology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Ophthalmology, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Kuang-I Cheng
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.
| | - Kwou-Yeung Wu
- Department of Ophthalmology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Ophthalmology, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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Turner Giannico A, de Sampaio MOB, Lima L, Corona Ponczek C, De Lara F, Montiani-Ferreira F. Characterization of the oculocardiac reflex during compression of the globe in Beagle dogs and rabbits. Vet Ophthalmol 2013; 17:321-7. [DOI: 10.1111/vop.12077] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Amália Turner Giannico
- Department of Veterinary Medicine; Federal University of Paraná; Rua dos Funcionários, 1540 Curitiba PR 80035-050 Brazil
| | - Manuella O. B. de Sampaio
- Department of Veterinary Medicine; Federal University of Paraná; Rua dos Funcionários, 1540 Curitiba PR 80035-050 Brazil
| | - Leandro Lima
- Department of Veterinary Medicine; Federal University of Paraná; Rua dos Funcionários, 1540 Curitiba PR 80035-050 Brazil
| | - Clara Corona Ponczek
- Department of Veterinary Medicine; Federal University of Paraná; Rua dos Funcionários, 1540 Curitiba PR 80035-050 Brazil
| | - Fátima De Lara
- Department of Veterinary Medicine; Federal University of Paraná; Rua dos Funcionários, 1540 Curitiba PR 80035-050 Brazil
| | - Fabiano Montiani-Ferreira
- Department of Veterinary Medicine; Federal University of Paraná; Rua dos Funcionários, 1540 Curitiba PR 80035-050 Brazil
- Department of Small Animal Clinical Sciences; D-208 Veterinary Medical Center; Michigan State University; East Lansing MI 48824 USA
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Oh JN, Lee SY, Lee JH, Choi SR, Chin YJ. Effect of ketamine and midazolam on oculocardiac reflex in pediatric strabismus surgery. Korean J Anesthesiol 2013; 64:500-4. [PMID: 23814649 PMCID: PMC3695246 DOI: 10.4097/kjae.2013.64.6.500] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Revised: 11/16/2012] [Accepted: 11/27/2012] [Indexed: 12/14/2022] Open
Abstract
Background The oculocardiac reflex (OCR) can be elicited during manipulation of the orbital structures in the strabismus correction surgery. A sinus bradycardia is the most common manifestation of OCR; and cardiac dysrhythmia and asystole may also occur. Various efforts to reduce OCR have been attempted, but without coherent outcome results. Methods Sixty one children, undergoing elective strabismus surgery, were randomly allocated into 2 groups: Group K received ketamine 1.0 mg/kg; and Group M received midazolam 0.15 mg/kg for induction of anesthesia. Anesthesia was maintained with 1-1.3 MAC of sevoflurane with 50% N2O in O2. Heart rate and blood pressure were measured 30 seconds before extraocular muscle (EOM) traction and immediately after traction. The OCR was defined as a decrease in heart rate more than 20% of the baseline heart rate, following manipulating EOM. Postoperative nausea and vomiting (PONV) and emergence agitation (EA) were assessed in postanesthetic care unit (PACU). Results Blood pressure before tightening EOM in Group K was higher than that in Group M (P < 0.05). However Δ HR (2.7 ± 15% vs. - 0.9 ± 16%) and incidence of OCR (10.0% vs. 19.4%) after traction an EOM were not different between the two groups. The occurrence of PONV (6.7 vs. 9.7%) and EA (30.0% vs. 22.6%) were similar. Conclusions Ketamine does not reduce the incidence of OCR compared with midazolam in pediatric strabismus surgery. In addition, ketamine does not increase the incidence of PONV and EA. In conclusion, it is reliable to use ketamine in pediatric strabismus surgery.
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Affiliation(s)
- Ji Na Oh
- Department of Anesthesiology and Pain Medicine, College of Medicine, Dong-A University, Busan, Korea
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Contopoulos-Ioannidis DG, Seto I, Hamm MP, Thomson D, Hartling L, Ioannidis JPA, Curtis S, Constantin E, Batmanabane G, Klassen T, Williams K. Empirical evaluation of age groups and age-subgroup analyses in pediatric randomized trials and pediatric meta-analyses. Pediatrics 2012; 129 Suppl 3:S161-84. [PMID: 22661763 DOI: 10.1542/peds.2012-0055j] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND An important step toward improvement of the conduct of pediatric clinical research is the standardization of the ages of children to be included in pediatric trials and the optimal age-subgroups to be analyzed. METHODS We set out to evaluate empirically the age ranges of children, and age-subgroup analyses thereof, reported in recent pediatric randomized clinical trials (RCTs) and meta-analyses. First, we screened 24 RCTs published in Pediatrics during the first 6 months of 2011; second, we screened 188 pediatric RCTs published in 2007 in the Cochrane Central Register of Controlled Trials; third, we screened 48 pediatric meta-analyses published in the Cochrane Database of Systematic Reviews in 2011. We extracted information on age ranges and age-subgroups considered and age-subgroup differences reported. RESULTS The age range of children in RCTs published in Pediatrics varied from 0.1 to 17.5 years (median age: 5; interquartile range: 1.8-10.2) and only 25% of those presented age-subgroup analyses. Large variability was also detected for age ranges in 188 RCTs from the Cochrane Central Register of Controlled Trials, and only 28 of those analyzed age-subgroups. Moreover, only 11 of 48 meta-analyses had age-subgroup analyses, and in 6 of those, only different studies were included. Furthermore, most of these observed differences were not beyond chance. CONCLUSIONS We observed large variability in the age ranges and age-subgroups of children included in recent pediatric trials and meta-analyses. Despite the limited available data, some age-subgroup differences were noted. The rationale for the selection of particular age-subgroups deserves further study.
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Affiliation(s)
- Despina G Contopoulos-Ioannidis
- Department of Pediatrics, Division of Infectious Diseases, Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, California 94305, USA.
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Wang X, Gorini C, Sharp D, Bateman R, Mendelowitz D. Anaesthetics differentially modulate the trigeminocardiac reflex excitatory synaptic pathway in the brainstem. J Physiol 2011; 589:5431-42. [PMID: 21930602 DOI: 10.1113/jphysiol.2011.215392] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
The trigeminocardiac reflex (TCR) occurs upon excitation of the trigeminal nerve with a resulting bradycardia and hypotension. While several anaesthetics and analgesics have been reported to alter the incidence and strength of the TCR the mechanisms for this modulation are unclear. This study examines the mechanisms of action of ketamine, isoflurane and fentanyl on the synaptic TCR responses in both neurones in the spinal trigeminal interpolaris (Sp5I) nucleus and cardiac vagal neurones (CVNs) in the Nucleus Ambiguus (NA). Stimulation of trigeminal afferent fibres evoked an excitatory postsynaptic current (EPSC) in trigeminal neurones with a latency of 1.8 ± 0.1 ms, jitter of 625 μs, and peak amplitude of 239 ± 45 pA. Synaptic responses further downstream in the reflex pathway in the CVNs occurred with a latency of 12.1 ± 1.1 ms, jitter of 0.8-2 ms and amplitude of 57.8 ± 7.5 pA. The average conduction velocity to the Sp5I neurones was 0.94 ± 0.18 mm ms(-1) indicating a mixture of A-δ and C fibres. Stimulation-evoked EPSCs in both Sp5I and CVNs were completely blocked by AMPA/kainate and NMDA glutamatergic receptor antagonists. Ketamine (10 μm) inhibited the peak amplitude and duration in Sp5I as well as more distal synapses in the CVNs. Isoflurane (300 μm) significantly inhibited, while fentanyl (1 μm) significantly enhanced, EPSC amplitude and area in CVNs but had no effect on the responses in Sp5l neurones. These findings indicate glutamatergic excitatory synaptic pathways are critical in the TCR, and ketamine, isoflurane and fentanyl differentially alter the synaptic pathways via modulation of both AMPA/kainate and NMDA receptors at different synapses in the TCR.
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Affiliation(s)
- Xin Wang
- Department of Pharmacology and Physiology, and Department of Anesthesiology and Critical Care Medicine, The George Washington University, 2300 Eye Street, NW, Washington, DC 20037, USA
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Anesthetic management for pediatric strabismus surgery: Continuing professional development. Can J Anaesth 2010; 57:602-17. [PMID: 20393822 DOI: 10.1007/s12630-010-9300-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2010] [Accepted: 03/05/2010] [Indexed: 12/16/2022] Open
Abstract
PURPOSE Strabismus surgery is one of the most common pediatric ophthalmic procedures. The purpose of this continuing professional development module is to update physicians on the anesthetic considerations of pediatric patients undergoing strabismus surgery. PRINCIPAL FINDINGS The preoperative assessment is important, as patients undergoing strabismus surgery may have an associated neuromuscular disorder, congenital syndrome, or cardiac disease. Malignant hyperthermia is no longer considered as being an issue associated with strabismus. The laryngeal mask airway is used frequently and has been shown as being associated with a low incidence of complications in strabismus surgery. The anesthesia technique can be adapted to decrease the incidence of the oculocardiac reflex and the oculorespiratory reflex, and the use of anticholinergic prophylaxis remains debatable. Since patients are at high risk for postoperative nausea and vomiting (PONV), combination anti-emetic therapy is recommended using dexamethasone and ondansetron. Metoclopramide was not found to provide additional benefit when combined with other anti-emetics. Droperidol is effective, but there remains a black box warning for dysrhythmias. Effective analgesics in this patient population include acetaminophen, nonsteroidal anti-inflammatory drugs, peribulbar blocks, and subtenon blocks. Topical tetracaine drops have demonstrated mixed results, and topical nonsteroidal anti-inflammatory drops were found not to be effective. The use of opioids should be minimized due to the increased incidence of PONV. CONCLUSIONS To provide optimal care for the pediatric patient undergoing strabismus surgery, it is important to understand the unique anesthetic considerations for strabismus surgery and to appreciate how each decision regarding the anesthetic technique can alter these considerations.
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Oh AY, Kim JH, Hwang JW, Do SH, Jeon YT. Incidence of postoperative nausea and vomiting after paediatric strabismus surgery with sevoflurane or remifentanil-sevoflurane. Br J Anaesth 2010; 104:756-60. [PMID: 20418533 DOI: 10.1093/bja/aeq091] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In this prospective, randomized, double-blind study, we evaluated and compared the incidence of postoperative nausea and vomiting (PONV) after paediatric strabismus surgery with two different anaesthetic methods, sevoflurane or remifentanil-sevoflurane. METHODS In total, 78 paediatric patients (aged 6-11 yr) undergoing strabismus surgery were enrolled and randomly assigned to two groups, sevoflurane (Group S) and remifentanil-sevoflurane (Group R). Anaesthesia was maintained with 2-3% sevoflurane in Group S (n=39) or with a continuous infusion of remifentanil combined with 1% sevoflurane in Group R (n=39), both using 50% N(2)O/O(2). Arterial pressure and heart rate before induction, after tracheal intubation, after skin incision, and at the end of surgery were recorded. The incidence of PONV in the post-anaesthesia care unit, the day surgery care unit, and at home 24 h after surgery was recorded. RESULTS Arterial pressure and heart rate were stable throughout the surgery, but were significantly lower in Group R than in Group S after tracheal intubation and skin incision. The incidence of PONV and postoperative vomiting was 17.9%/17.9% and 12.8%/10.2% (Group S/Group R) at the respective time points; values were comparable between the groups. CONCLUSIONS The incidence of PONV after paediatric strabismus surgery under sevoflurane anaesthesia was relatively low, and combining remifentanil with sevoflurane did not further increase the incidence.
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Affiliation(s)
- A Y Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
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Singh J, Roy S, Mukherjee P, Konar D, Konar A, Hazra S. Influence of topical anesthetics on oculocardiac reflex and corneal healing in rabbits. Int J Ophthalmol 2010; 3:14-8. [PMID: 22553509 DOI: 10.3980/j.issn.2222-3959.2010.01.04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2009] [Accepted: 01/07/2010] [Indexed: 11/02/2022] Open
Abstract
AIM To investigate the incidence of oculocardiac reflex (OCR) with two anesthetic regimens and its prevention using topical anesthetics in a rabbit model, and to explore the effect of topical anesthetics on corneal healing. METHODS Forty-eight clinically healthy adult New Zealand white rabbits of either sex were divided into two groups (Group A and B) and anesthetized with either ketamine (Group A, n =24) or propofol (Group B, n =24). he incidence of OCR was recorded in each group with a variety of ocular manipulation with or without the use of topical anesthetics (40g/L lignocaine, 5g/L proparacain, 5g/L bupivacaine). Corneal toxicity and healing following the use of each topical anesthetic was assessed one day after surgery and up to 7 days postoperatively by clinical examination of the eye, histopathology and collagen staining and transmission electron microscopy. RESULTS No incidence of OCR was recorded with ocular manipulation under ketamine anesthesia, whereas significant reduction in heart rate (P<0.01) was recorded under propofol anesthesia. Topical anesthetics could successfully prevent the OCR without affecting the corneal healing. CONCLUSION Topical anesthetics may be recommended for prevention of OCR without any local adverse effect.
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Affiliation(s)
- Jay Singh
- West Bengal University of Animal and Fishery Sciences, Kolkata, India
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Choi SR, Park SW, Lee JH, Lee SC, Chung CJ. Effect of different anesthetic agents on oculocardiac reflex in pediatric strabismus surgery. J Anesth 2009; 23:489-93. [PMID: 19921355 DOI: 10.1007/s00540-009-0801-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2009] [Accepted: 05/28/2009] [Indexed: 11/25/2022]
Abstract
PURPOSE The oculocardiac reflex (OCR) occurs frequently during pediatric strabismus surgery. The aim of this study was to assess the effects of various anesthetic regimens on the incidence of OCR during the surgery. METHODS Two hundred and eighty children, 1 to 9 years old, undergoing elective strabismus surgery, were randomly assigned to eight groups; ketamine-sevoflurane (KS), ketamine-desflurane (KD), ketamine-propofol (KP), ketamine-remifentanil (KR), midazolam-sevoflurane (MS), midazolam-desflurane (MD), midazolam-propofol (MP), and midazolam-remifentanil (MR). No premedication was given. Anesthesia was induced using ketamine 1 mg kg(-1) or midazolam 0.15 mg kg(-1) with 66% N(2)O in O(2). Laryngeal mask airways (LMAs) were placed with rocuronium 0.5 mg kg(-1). Anesthesia was maintained with sevoflurane 2-3 vol. %, desflurane 5-6 vol. %, propofol 7-8 mg kg(-1) h(-1), or remifentanil 0.75 microg kg(-1) over 1 min, followed by a continuous infusion of remifentanil 0.5 microg kg(-1) min(-1) with 66% N(2)O in O(2). Heart rate (HR) was recorded during extraocular muscle (EOM) manipulation. OCR was defined as a reduction in HR of more than 20% induced by the traction of an EOM. RESULTS In patients given ketamine, OCR occurred more frequently in the KP (65.7%) and KR (62.9%) groups than in the KD (29.4%) and KS (37.1%) groups (P < 0.05). In patients given midazolam, OCR occurred more frequently in the MP (54.3%) and MR (60.6%) groups than in the MD (36.4%) and MS (31.4%) groups (P < 0.05). CONCLUSION Propofol or remifentanil anesthesia was associated with a higher incidence of OCR during pediatric strabismus surgery than sevoflurane and desflurane anesthesia, when either ketamine or midazolam was used as an induction agent.
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Affiliation(s)
- So Ron Choi
- Department of Anesthesiology and Pain Medicine, Dong-A University Hospital, Seo-gu, Busan, Korea
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Garg R. Remifentanil-induced bradycardia or oculocardiac reflex during strabismus surgery? Acta Anaesthesiol Scand 2009; 53:548-9. [PMID: 19317872 DOI: 10.1111/j.1399-6576.2008.01898.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Yi C, Jee D. Influence of the anaesthetic depth on the inhibition of the oculocardiac reflex during sevoflurane anaesthesia for paediatric strabismus surgery. Br J Anaesth 2008; 101:234-8. [PMID: 18524784 DOI: 10.1093/bja/aen129] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- C Yi
- Department of Anaesthesiology and Pain Medicine, Yeungnam University College of Medicine, Daemyung-Dong, Nam-Gu, Daegu 705-035, Republic of Korea
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