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Prediction of the Occurrence of the Oculocardiac Reflex Based on the Assessment of Heart Rate Variability. An Observational Study. Ophthalmol Ther 2022; 11:1857-1867. [PMID: 35913657 PMCID: PMC9437188 DOI: 10.1007/s40123-022-00549-0] [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: 06/02/2022] [Accepted: 06/30/2022] [Indexed: 11/08/2022] Open
Abstract
Introduction Ophthalmic surgery is assumed to be safe, but some operations require general anaesthesia which is associated with a number of potential complications. In addition, adverse cardiovascular symptoms, such as severe slowing of the heart rate and, in some cases, cardiac arrest may occur due to the surgical technique. The aim of this study was to determine whether it is possible to predict the occurrence of oculocardiac reflex (OCR) based on heart rate variability (HRV) analysis for autonomic nervous system (ANS) activity assessment measured prior to the induction of anaesthesia and immediately before eyeball traction. Methods Fifty-two adults of both sexes (age range 18–65 years) with American Society of Anesthesiologists (ASA) physical status class 1 and 2 were enrolled in this study. All patients had underwent episcleral buckling under general anaesthesia. High-frequency (HF) changes in HRV are thought to reflect parasympathetic impulse transmission, whereas low-frequency (LF) changes reflect both sympathetic and parasympathetic activity. However, in practice, LF changes can be considered to reflect sympathetic changes. Thus, the LF/HF ratio reflects the actual balance between sympathetic and parasympathetic activity. Based on that, frequency domain HRV parameters from 5-min Holter electrocardiogram recordings before anaesthesia induction and before eyeball traction were used for the analysis. The statistical analysis also included patient age, sex, ASA status and preanaesthesia and premanoeuvre heart rate and blood pressure. Results Data from 42 patients were analysed. Oculocardiac reflex was observed in 32 patients (76.2%). No difference was found in the analysed parameters between patients with and without oculocardiac reflex. There was no relationship between the incidence of the OCR and the analysed parameters. Conclusion The prediction of OCR based on initial ANS tone was not possible, and the initial heart rate, blood pressure, age, sex, and ASA status were not helpful for the identification of patients at risk of this reflex. Trial registration ClinicalTrials.gov identifier no.: NCT01714362
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Abstract
BACKGROUND A typical oculocardiac reflex (OCR) is a moderate trigemino-vagal bradycardia elicited by tension on an extraocular muscle (EOM) during strabismus surgery; however, many other orbital stimuli can elicit cardiac slowing including retinopathy of prematurity examination. METHODS World literature related to trigeminovagal and oculocardiac reflex covering over 15,000 patients including 51 randomized clinical trials and case reports are analyzed and reviewed. Under an ongoing observational trial in Alaska, anesthetic, patient and surgical influences on routine strabismus surgery using prospective, uniform EOM tension are compared seeking sufficient sample size to characterize this individually widely variable cardiac response. RESULTS With adequate sample size, and emphasizing clinical studies controlling type of EOM, muscle tension amount and duration, anticholinergic and opioid medications, the following augment OCR; rapid-acting opioids and dexmedetomidine while OCR is reduced in older patients, the right eye, less EOM tension, deeper inhaled agents, hypocarbia, anticholinergic medications and orbital block. In re-operations, the former are relatively poor predictors of subsequent OCR. CONCLUSION Profound bradycardia can occur in almost 10% of strabismus surgery cases without anticholinergic preventive measures, but reliable prediction of OCR remains elusive. With foreknowledge and careful anesthetic monitoring of the patient before EOM manipulation, residual adverse sequelae from OCR are fortunately very rare. Despite well over a century of experience, the teleology for this occasionally dramatic cardiac response to eye surgery is still not known.
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Affiliation(s)
- Robert W Arnold
- The Alaska OCR Study, Alaska Blind Child Discovery, Alaska Children’s EYE & Strabismus, Anchorage, AK, 99508, USA
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Leão P, Castro D, Pacheco M, Soares JC, Afonso D. Outcome of combined peribulbar ropivacaine 0.75% block and general anesthesia for retinal detachment surgery: A randomized controlled study. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2016.08.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Pedro Leão
- Anesthesiologist of the Department of Anesthesiology and Pain Medicine, Centro Hospitalar de Entre o Douro e Vouga, 4520-211 Santa Maria da Feira, Portugal
| | - Diogo Castro
- Anesthesiologist of the Department of Anesthesiology and Pain Medicine, Centro Hospitalar de Entre o Douro e Vouga, 4520-211 Santa Maria da Feira, Portugal
| | - Marcos Pacheco
- Anesthesiologist of the Department of Anesthesiology and Pain Medicine, Centro Hospitalar de Entre o Douro e Vouga, 4520-211 Santa Maria da Feira, Portugal
| | - José C. Soares
- Anesthesiologist at the Department of Anesthesiology, Centro Hospitalar Póvoa de Varzim – Vila do Conde, 4480 Vila do Conde, Portugal
| | - Diana Afonso
- Anesthesiologist of the Department of Anesthesiology and Pain Medicine, Centro Hospitalar de Entre o Douro e Vouga, 4520-211 Santa Maria da Feira, Portugal
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Arnold RW, Bond AN, McCall M, Lunoe L. The oculocardiac reflex and depth of anesthesia measured by brain wave. BMC Anesthesiol 2019; 19:36. [PMID: 30871507 PMCID: PMC6417239 DOI: 10.1186/s12871-019-0712-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 03/10/2019] [Indexed: 12/27/2022] Open
Abstract
Background The oculocardiac reflex (OCR), bradycardia that occurs during strabismus surgery is a type of trigemino-cardiac reflex (TCR) is blocked by anticholinergics and enhanced by opioids and dexmedetomidine. Two recent studies suggest that deeper inhalational anesthesia monitored by BIS protects against OCR; we wondered if our data correlated similarly. Methods In an ongoing, prospective study of OCR/TCR elicited by 10-s, 200 g square-wave traction on extraocular muscles (EOM) from 2009 to 2013, anesthetic depth was estimated in cohorts using either BIS or Narcotrend monitors. The depth of anesthesia was deliberately varied between first and second EOM tested. Results From 1992 through 2013, 2833 cases of OCR during strabismus surgery were monitored. Excluding re-operations and cases with anticholinergic, OCR from first EOM traction averaged − 20.2 ± 21.8% (S.D.) with a range from − 95 to + 25% in patients aged 0.2 to 90 (median 6.5) years. We did not find correlation between %OCR and brain wave for 97 patients with BIS monitoring and 91 with Narcotrend. With intra-patient controls between first and second muscle, the difference in brain wave did not correlate with difference in %OCR for BIS (r = 0.0002, 95% C. I -0.0002, 0.002, p = 0.30) or for Narcotrend (r = − 0.001, 95% C. I -0.004, 0.001, p = 0.32). Secondary multi-variable analysis demonstrated significant association on %OCR particularly with BIS monitor, opioid, propofol and nitrous oxide concentration in the second EOM tensioned. Sevoflurane concentration correlated better with BIS monitor in second and third EOM tension. %OCR correlated with younger age (p < 0.01). OCR with rapid onset was more profound than those with gradual onset (difference in means 18, 95% C. I 10, 26%). Conclusions We were unable to confirm a direct correlation between brain wave monitor and OCR when using multifactorial anesthetic agents. The discrepency with other studies probably reflects direct impact of inhalational agent concentration and less deliberate quantification of EOM tension. We found no level of BIS or Entropy EEG monitoring that uniformly prevents OCR. Trial registry NCT03663413. Data: http://www.abcd-vision.org/OCR/OCR%20Brainwave%20de-identified.pdf.
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Affiliation(s)
- Robert W Arnold
- Alaska Children's EYE & Strabismus, 3500 Latouche St #280, Anchorage, Alaska, 99508, USA.
| | - Aleah N Bond
- Alaska Children's EYE & Strabismus, 3500 Latouche St #280, Anchorage, Alaska, 99508, USA
| | | | - Leif Lunoe
- Providence Anesthesia Group, Anchorage, Alaska, USA
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Arnold RW, Biggs RE, Beerle BJ. Intravenous dexmedetomidine augments the oculocardiac reflex. J AAPOS 2018; 22:211-213.e1. [PMID: 29733898 DOI: 10.1016/j.jaapos.2018.01.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Revised: 01/12/2018] [Accepted: 01/17/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND We reported that premedication with nasal dexmedetomidine was associated with a more intense oculocardiac reflex (OCR). In this study we performed an intrasubject, intravenous comparison to test our hypothesis that this alpha-adrenergic agonist potentiates the trigemino-vagal reflex. METHODS OCR (greatest change heart rate/baseline heart rate) was prospectively monitored with 10-second, square-wave 200 g tension on the inferior rectus or other muscles during strabismus surgery. Between the first and second muscle, intravenous dexmedetomidine 0.5 μg/kg was delivered. RESULTS All patients had no anticholinergic agents. A total 842 historic control patients (median age, 5.5 years) with no dexmedetomidine between muscles experienced the first OCR of 75% ± 24% (SD) and the second OCR of 77% ± 22%. The 33 study patients (median age, 5.6 years) experienced the first OCR 84% ± 16% and dexmedetomidine second OCR of 66% ± 25% for a bradycardia augmentation of 18% ± 19% (P < 0.01 [Mann-Whitney]). CONCLUSIONS Similar to the effect of fentanyl, intravenous fast-push dexmedetomidine augmented the bradycardia associated with extraocular muscle traction.
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Effects of an infratrochlear nerve block on reducing the oculocardiac reflex during strabismus surgery: a randomized controlled trial. Graefes Arch Clin Exp Ophthalmol 2018; 256:1777-1782. [DOI: 10.1007/s00417-018-4001-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 04/16/2018] [Accepted: 04/20/2018] [Indexed: 11/26/2022] Open
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Abouammoh MA, Abdelhalim AA, Mohamed EA, Elzoughari I, Mustafa M, Al-Zahrani TA. Subtenon block combined with general anesthesia for vitreoretinal surgery improves postoperative analgesia in adult: a randomized controlled trial. J Clin Anesth 2016; 30:78-86. [DOI: 10.1016/j.jclinane.2015.11.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 09/04/2015] [Accepted: 11/30/2015] [Indexed: 10/22/2022]
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Ghali AM, El Btarny AM. The effect on outcome of peribulbar anaesthesia in conjunction with general anesthesia for vitreoretinal surgery. Anaesthesia 2010; 65:249-53. [DOI: 10.1111/j.1365-2044.2009.06191.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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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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Kang HG, Keun-Hae K. Oculocardiac Reflex during Ptosis Operation under Local Anesthesia. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2008. [DOI: 10.3341/jkos.2008.49.1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Hyun-Gu Kang
- Department of Ophthalmology, College of Medicine, Catholic University of Daegu, Daegu, Korea
| | - Kim Keun-Hae
- Department of Ophthalmology, College of Medicine, Catholic University of Daegu, Daegu, Korea
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Morel J, Pascal J, Charier D, De Pasquale V, Gain P, Auboyer C, Molliex S. Preoperative Peribulbar Block in Patients Undergoing Retinal Detachment Surgery Under General Anesthesia: A Randomized Double-Blind Study. Anesth Analg 2006; 102:1082-7. [PMID: 16551903 DOI: 10.1213/01.ane.0000198638.93784.42] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Retinal detachment surgery is frequently associated with significant postoperative pain and emesis in adults. In this randomized, double-blind, controlled study we sought to demonstrate that 1% ropivacaine peribulbar (PB) block in conjunction with general anesthesia (GA) improves operative conditions and postoperative analgesia compared with GA combined with subcutaneous normal saline injection into the inferior eyelid. Thirty-one patients were included in each group. Anesthesia was performed with target-controlled infusion propofol and continuous remifentanil infusion adjusted to maintain bispectral index values between 40 and 50. Postoperative analgesia included fixed-dose IV infusion of propacetamol and IV injection of nefopam via a patient-controlled analgesia device. Tramadol was infused IV as rescue medication. Demographic data were comparable between the groups and bispectral index values were maintained at the objective target. In the PB group, fewer patients presented an oculocardiac reflex (6 versus 17; P < 0.01); bleeding interfering with the surgical field was reduced (1 versus 11 patients; P < 0.01); mean time to first nefopam request was longer (148 +/- 99 versus 46 +/- 58 min; P < 0.01); mean nefopam consumption was diminished during the first 6 h after tracheal extubation (18.9 +/- 13.9 versus 28.5 +/- 14.7 mg; P < 0.05); immediate postoperative pain scores were lower; and fewer patients required rescue medication (5 versus 23; P < 0.01). The two groups were similar with respect to the incidence of postoperative nausea and vomiting. Overall, PB block combined with GA improved operating conditions and postoperative analgesia in retinal detachment surgery.
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Affiliation(s)
- Jérôme Morel
- Département d'Anesthésie-Réanimation, Hôpital Bellevue, 42055 Saint-Etienne cedex 2, France
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Abstract
Cardiac arrhythmias are common in the perioperative period. Most arrhythmias are clinically benign. Occasionally, cardiac arrhythmias and conduction disturbances can pose a major additional risk to the patient in the perioperative and postoperative periods. The current availability of a wide array of techniques for controlling serious arrhythmias--pharmacologic, electrical, and interventional--enable the physician to manage most arrhythmias and conduction disturbances successfully. The added risks posed by arrhythmias and conduction disturbances in the perioperative period now can be minimized.
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Affiliation(s)
- S B Sloan
- Division of Cardiology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Paciuc M, Mendieta G, Naranjo R, Angel E, Reyes E. Oculocardiac reflex in sedated patients having laser in situ keratomileusis. J Cataract Refract Surg 1999; 25:1341-3. [PMID: 10511932 DOI: 10.1016/s0886-3350(99)00209-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To eliminate stress as a variable in assessing the frequency of the oculocardiac reflex during laser in situ keratomileusis (LASIK). SETTING Merida Ophthalmological Hospital and Oftalmedica, Mexico City, Mexico. METHODS A pulse oximeter registered the heart rate of 30 sedated patients having LASIK. Sedation was accomplished with a combination of midazolam and fentanyl. The heart rate was noted before and during suction. The results in 1 eye of each patient were recorded. Oculocardiac reflex was defined as a decrease of 10% or more of the basal heart rate. RESULTS Fourteen patients (46.7%) had a 10% or more decrease in heart rate when suction was applied. Ten of the 14 had a decrease in heart rate between 10% and 19%, 3 between 20% and 29%, and 1 of more than 30%. Two patients (6.6%) had an increase in the basal heart rate of more than 10%. CONCLUSIONS The findings suggest that the oculocardiac reflex occurs more frequently in sedated patients than in nonsedated patients.
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