Comparison of the Sedation Quality of Etomidate, Propofol, and Midazolam in Combination with Fentanyl During Phacoemulsification Cataract Surgery: A Double-Blind, Randomized, Controlled, Clinical Trial

Successful Use of Low-Dose Combination Propofol and Fentanyl in Cataract Surgery Phacoemulsification

Background

The combination between sedatives and opioids is one of the recommended anesthetic options in ophthalmic procedures and regimens are more advantageous as smaller amounts of each drug can be administered to reduce side effects and have proper outcomes due to the synergistic effects. This study aims to observe the use of low-dose propofol and fentanyl for patients undergoing phacoemulsification surgery.

Material and Methods

This observational study involves a sample of 125 adult patients who underwent elective cataract procedures using the phacoemulsification technique and had an American Society of Anesthesiologists (ASA) physical status of 1 to 3. Dose amount of fentanyl and propofol, Ramsay score, hemodynamic parameter, side effects, and patient satisfaction were evaluated, recorded, and analyzed using a 5-point Likert scale.

Results

The result showed the mean absolute dose of propofol was 12.46±4.376 mg, with a range between 10 and 30 mg, while the mean per body weight was 0.21±0.075 mg. Similarly, the mean absolute dose for fentanyl was 25.04±3.012 mcg within the range of 10-50 mcg, and the per-body weight dose was 0.43±0.080 mcg. About 90.4% and 9.6% of the patients reached Ramsay 2 and 3, respectively. The analysis of systolic, diastolic blood pressure, mean arterial pressure, and pulse rate showed that the combination of low-dose fentanyl and propofol was significantly lower than before therapy administration in all four values (p < 0.05).

Conclusion

The combination of low-dose propofol and fentanyl in cataract surgery using phacoemulsification successfully reached the targeted sedation level and a significant decrease in blood pressure, MAP, pulse rate, minimal side effects, and high satisfaction rate.

Evaluating the preventive effect of metoclopramide and aminophylline on pain after deep vitrectomy

BACKGROUND

Deep vitrectomy is one of the most frequently performed ophthalmic procedures. Postoperative pain is a common complaint among patients. Consequently, we investigated whether metoclopramide and aminophylline could decrease pain intensity following deep vitrectomy.

METHODS

This double-blinded clinical trial study that was approved by the Ethical Committee of Isfahan University of Medical Sciences (IR.MUI.REC.1396.3.217) (Thesis Reg. number: 396217) and registered at the Iranian Registry of Clinical Trials (IRCT) (Reg. number: IRCT20170716035104N5, available at https://www.irct.ir/trial/59146) aimed to evaluate 105 patients who were candidates for deep vitrectomy. They were randomly assigned into three groups: metoclopramide (received 0.1 mg/kg diluted in 10 ml of normal saline), aminophylline (received 4 mg/kg diluted in 10 ml of normal saline), and placebo (received 10 ml of normal saline). Postoperative pain was evaluated in all groups.

RESULTS

The postoperative pain levels of the three groups differed significantly from the start of the recovery to 30 minutes, 60 minutes, 2 hours, and 4 hours postoperatively, with metoclopramide and aminophylline groups experiencing less postoperative pain than the placebo group. Moreover, there was a significant difference between the groups regarding patient satisfaction (P<0.05).

CONCLUSION

Both metoclopramide and aminophylline significantly reduce postoperative pain after deep vitrectomy, although metoclopramide has a greater effect.

Comparison of the Sedative, Hemodynamic, and Anesthetic Effect of Dexmedetomidine, Ketamine, and Etomidate on Cataract Surgery by Phacoemulsification Method: A Randomized Clinical Trial

Purpose

To compare dexmedetomidine, ketamine, and etomidate in the induction of sedation and hemodynamic changes in patients undergoing cataract surgery by phacoemulsification method.

Methods

This was a double-blind clinical trial study carried out on 128 patients. Using the block randomization method, the patients were divided into four equal groups (dexmedetomidine, ketamine, etomidate, and control). Mean arterial pressure, heart rate, and arterial oxygen saturation, Ramsay Sedation Score were recorded every 5 min intraoperatively, in recovery, and 1, 2, 4, and 6 h postoperatively. Moreover, the Aldrete score was measured in recovery time for discharge from the recovery room.

Results

The mean age of participants was found to be 63.16 ± 6.07 years, and there was no statistically significant difference between the groups in terms of age, sex, and body mass index, SpO_2, and heart rate (P > 0.05). From 15 min after the start of surgery to 6 h postoperatively, the mean arterial pressure in the dexmedetomidine group was significantly lower than that in the other three groups, including ketamine, etomidate, and control (P < 0.05). The mean sedation score (Ramsay) during recovery and 1 h postoperatively was higher in the dexmedetomidine group compared with that in the control group, whereas the recovery time in the dexmedetomidine group was higher than that in the other groups (P < 0.001). In addition, the amount of propofol consumption in the two groups of dexmedetomidine and ketamine was significantly less than that in the etomidate and control groups (P < 0.001).

Conclusions

According to the results, dexmedetomidine caused better hemodynamic changes with more reduction in blood pressure and heart rate, and patients in the dexmedetomidine group did not require any specific medical treatment. Moreover, higher patient satisfaction and longer recovery duration were observed in the dexmedetomidine group than in the other study groups. As such, it is suggested that dexmedetomidine be used as an adjuvant in cataract surgery for more sedation, analgesia, and optimal intraoperative conditions.

Efficacy of a premedication with melatonin during cataract surgery under peribulbar block: a prospective randomized double-blinded study

INTRODUCTION

Cataract is a ubiquitous pathology. Its prevalence increases with age. Nowadays, cataract surgery is increasingly performed on an outpatient basis under locoregional anesthesia. In this context, sedation-analgesia is essential but not without risks.

AIM

To evaluate the effectiveness of premedication with melatonin on intraoperative sedation-analgesia.

METHODS

This is a prospective randomized double-blind study including patients proposed for scheduled cataract surgery by phacoemulsification under peribulbar anesthetic block. The participants will be randomized into two groups: group (M) will receive 05 tablets of melatonin (10mg sublingual) and group (P) will receive 05 tablets of Sucralose sublingually. Perioperative sedation-analgesia will be evaluated by the Ramsey score, the bisectral index, the simple verbal scale (EVS) and by the perioperative consumption of midazolam and alfentanyl. Secondary endpoints will be the degree of preoperative anxiety (Amsterdam Preoperative, Anxiety and Information Scale), the perioperative tonus of the eyeball, intraoperative nicardepine consumption and patients and surgeons satisfaction. A value of p <0.05 will be considered statistically significant.

EXPECTED RESULTS

The administration of melatonin as a premedication for scheduled cataract surgery will allow a better quality of intraoperative sedationanalgesia, a reduction in the doses consumed of midazolam and alfentanyl, improves surgical conditions, leads to a decrease in ocular tone, and optimizes surgical safety conditions for the patient.

A Comparative Study of the Effect of Anesthesia Induction with the Use of Four Drug Combinations Including "Propofol," "Etomidate-Propofol," "Thiopental," and "Midazolam-Thiopental" on Hemodynamic Changes during the Insertion of Laryngeal Mask in Eye Surgery

Background

This study aimed to compare the efficacies of four anesthetic induction drugs (thiopental, propofol, midazolam-thiopental, and etomidate-propofol) on cardiovascular response during laryngeal mask airway (LMA) placement in eye surgery.

Materials and Methods

The present clinical trial study included 128 patients who were candidates for ophthalmic surgery in four groups. Patients in the first group were given a combination of midazolam (0.04 mg/kg) with thiopental (2.5 mg/kg) (Group T + M). We administered propofol alone (2.5 mg/kg) to patients in the second group (Group P). The third group received a combination of etomidate (0.1 mg/kg) with propofol (1 mg/kg) (ET + P group) and patients in the fourth group received thiopental drug (5 mg/kg) alone (Group T). Then, the stability of patients' hemodynamic parameters before anesthesia was evaluated and compared immediately after anesthesia, 1, 3, and 5 min after LMA placement.

Results

There was no significant difference between the four groups in changes in oxygen saturation level (P > 0.05). Furthermore, the difference between decreased systolic blood pressure and diastolic blood pressure over time was not significant in 5 min in both Groups T + M and T (P > 0.05). In addition, the stability of these two groups was higher than the other two groups (P < 0.05) and the most unstable group was Group P. The changes pulse ratein the P group were significant (P < 0.05).

Conclusion

According to the results of the current study, thiopental and Midazolam can be used as an effective induction compound to facilitate LMA insertion with higher hemodynamic stability compared to propofol alone, propofol and etomidate, and thiopental alone.

Vitreoretinal Surgery Under Sub-Tenon’s Block and Conscious Sedation in a Patient with Brugada Syndrome: A Case Report and Literature Review

Brugada syndrome (BrS), a type of sudden arrhythmic unexpected death syndrome (SADS), is characterized by specific electrocardiogram (ECG) changes, a structurally normal heart, and susceptibility to life-threatening ventricular arrhythmias. General anesthesia (GA) is usually used for major surgery in patients with BrS due to concerns that some local anesthetic agents may precipitate critical arrhythmias. The majority of ophthalmic surgeries are successfully carried out under regional anesthesia (RA). The literature does not address the use of ophthalmic RA in patients with BrS except one report of peribulbar block for glaucoma surgery. This clinical case report and the liertature review suggests that for BrS patients presenting for vitreoretinal surgery, a sub-tenon block, with or without sedation may safely be used as a primary anaethestic technique.

Perioperative Anxiolytic and Analgesic Effects of Pregabalin in Vitreo-Retinal Surgery: A Randomized, Double-blind Study

Objectives

This study was done to examine the effect of a single, one-time pregabalin dose on postoperative pain, anxiety, and analgesic consumption after vitrectomy performed under the peribulbar block and to assess the satisfaction of the patients as well as the surgeons.

Methods

This randomized, double-blinded, placebo-controlled trial was conducted at Magrabi Eye, ENT and Dental Center, Doha, Qatar on 58 adult patients aged 37 - 75 years, who met status I and II of the American Society of Anesthesiologists (ASA) and scheduled for elective vitrectomy, under the peribulbar block (PB). Of the total participants, 30 cases were randomized to receive pregabalin, while the remaining received placebo 90 minutes before surgery. Pain was assessed using a Verbal Analog Scale (VAS) score, and the levels of anxiety were gauged by verbal anxiety score.

Results

Patients who received pregabalin had a significantly higher sedation score (3 ± 0 vs. & 2 ± 0.65; P < 0.05), and a significantly less anxiety score (3 ± 1.3 vs. 5 ± 1.6; P < 0.001) compared to the control group. During needle insertion for PB, patients in the pregabalin group experienced less pain compared to the control group (32 ± 15 vs. 44 ± 15; P < 0.05). Pregabalin group showed a significantly higher cooperation rate and patient satisfaction scores (3.2 ± 0.7 and 3.8 ± 0.4, respectively), compared to the placebo group (2.8 ± 0.7 and 3.4 ± 0.5, respectively). The placebo group required intraoperative midazolam more in comparison to the pregabalin group (19 vs. 5; P < 0.001). Moreover, the need for postoperative analgesia was more in the placebo group two hours postoperatively.

Conclusions

Pregabalin is a potent premedication in controlling post-surgical pain and anxiety in patients undergoing vitrectomy under the PB.

Practical Considerations for Dexmedetomidine Sedation in Adult Cataract Surgery Under Local/Regional Anesthesia: A Narrative Review

Cataract surgery is predominantly performed under local/regional anesthesia, with or without sedation. The practice pattern of sedation is unknown and seems to vary significantly among institutions and countries, routinely administered in some parts of the world to the other extreme of none at all. The selection of sedative agents and techniques varies widely. Currently, there is no ideal sedative agent. Dexmedetomidine has gained recent attention for sedation in ophthalmic local/regional anesthesia due to its alleged advantages of effective sedation with minimal respiratory depression, decreased intraocular pressure, and reduced pain during the local anesthetic injection; however, they are subject to differing interpretations. Published literature also suggests that although dexmedetomidine sedation for cataract surgery under local/regional anesthesia is potentially useful, its role may be limited due to logistical difficulties in administering the recommended dose.

A Comparative Study of Valsalva Maneuver, Lidocaine, and Valsalva Maneuvers with Administration of Lidocaine to Reduce the Pain Associated with Administration of Etomidate During General Anesthesia

Objectives

The purpose of this study is a comparison of Valsalva, lidocaine, and Valsalva with administration of lidocaine to reduce the pain associated with administration of etomidate.

Methods

The present study is a clinical trial study. The number of samples in each group was 30 and a total of 90 people were selected. This study was a clinical trial and the subjects were randomly divided into three groups: Group 1: Valsalva, 2: Lidocaine, 3: Valsalva and Lidocaine. Pain due to etomidate was rated on a VAS from 1 (painless) to 3 (worst imaginable pain) and their information was recorded. The collected information was entered into SPSS 22 and analyzed with appropriate statistical tests.

Results

A total of 90 subjects participated in the present study and were divided into 3 groups: Valsalva, lidocaine, and Valsalva with lidocaine. No significant difference was observed between demographic variables in the study groups. There was a significant relationship between severity of pain in the three groups. According to the results, the highest pain intensity was in the Valsalva group and the lowest pain intensity was in the Valsalva with lidocaine group.

Conclusions

Valsalva with lidocaine reduces the severity of pain caused by etomidate to a greater extent than other groups.

Anesthesia Considerations for Cataract Surgery in Patients with Schizophrenia: A Narrative Review

Schizophrenia is ranked among the top 10 global burdens of disease. About 1% of people meet the diagnostic criteria for this disorder over their lifetime. Schizophrenic patients can develop cataract, particularly related to age and medications, requiring surgery and anesthesia. Many concerning factors, including cognitive function, anxiety, behavioral issues, poor cooperation and paroxysmal movements, may lead to general anesthesia as the default method. Antipsychotic agents should be continued during the perioperative period if possible. Topical/regional anesthesia is suitable in most schizophrenic patients undergoing cataract surgery. It reduces potential drug interactions and many postoperative complications; however, appropriate patient selection is paramount to its success. General anesthesia remains the primary technique for patients who are considered unsuitable for the topical/regional technique. Early involvement of a psychiatrist in the perioperative period, especially for patients requiring general anesthesia, is beneficial but often under-utilized. This narrative review summarizes the anesthetic considerations for cataract surgery in patients with schizophrenia.

Effect of Benson's Relaxation Technique on Propofol Consumption and Preoperative Anxiety of Patients Undergoing Cataract Surgery

Background

Benson’s relaxation (BR) technique is a suitable non-pharmacological approach to reduce preoperative anxiety (PA).

Objectives

This study aimed to investigate the effect of BR therapy on PA and the induction and maintenance dose of propofol during cataract surgery (CS).

Methods

Seventy-two patients were randomly divided into two experiments or BR and control groups. The Amsterdam and Spielberger State-Trait Anxiety inventory (STAI) scores were used to assess PA directly two days and a half-hour before the CS. The control group did not receive any preoperation intervention or relaxation. Benson’s relaxation method was performed three times, each time for 20 minutes, including two days before surgery, a night before surgery, and an hour before the surgery in the presence of a researcher by an audio file. The induction and maintenance dose of anesthetic drug was recorded and compared between the two groups.

Results

The mean propofol consumption was significantly reduced during the induction of anesthesia in the intervention group compared to the control group (0.99 ± 0.29 versus 1.29 ± 0.49; P = 0.005) as well as the maintenance of anesthesia (84.66 ± 17.98 versus 108.33 ± 34.38, P = 0.001). The results of the post-intervention Amsterdam anxiety score showed a significant decrease in the intervention group compared to the control group (P = 0.032, F = 9.61, Eta2 = 0.12). The control group showed a higher Spielberger state score compared to the intervention group as well as the Spielberger trait (P < 0.001, F = 14.78, Eta2 = 0.18).

Conclusions

The BR method effectively reduces the level of PA in patients undergoing CS. Moreover, it reduces the need for anesthetic drug, propofol, during surgery.