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Complications of Retrobulbar Blocks

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Complications of Retrobulbar Blocks Patient Safety Advisory Produced by ECRI Institute & ISMP under contract to the Patient Safety Authority Complications of Retrobulbar Blocks ver two dozen reports of retrobulbar hemor- Indications O rhages and at least three cases of respiratory If a retrobulbar block is considered, several factors arrest have been submitted to PA-PSRS since the will reduce the risk of complications. program’s inception in June 2004. These reports represent complications of the retrobulbar block, an Cooperation anesthetic technique used for intraocular surgery The patient must be able to follow instructions and that many practitioners are abandoning in place of cooperate with the surgical team.3,4 In order to follow topical anesthetics. directions, patients should not be hearing impaired or deaf, nor should there be a language barrier be- Declining Use of Retrobulbar Blocks tween the patient and surgical team.3,5,6 Hearing A recent survey indicates a move away from retro- aids, sign language interpreters, and/or foreign lan- bulbar blocks, while topical anesthesia is gaining guage interpreters may enhance cooperation. 1 greater acceptance. A 2003 survey of physician members of the American Society of Cataract and Positioning Refractive Surgery in the United States revealed this 3,5 2 The patient must be able to lie flat on his/her back. trend, presented in Table 1. Whereas in 1985, 76% As a result, diagnoses that prevent such a position of survey respondents used retrobulbar blocks with would be contraindications, such as severe back facial block, in 2003 only 17% of respondents used pain,4 postural problems,4 or chronic cardiac or res- this modality. The use of topical anesthesia has in- piratory problems.6 creased from 8% in 1995 to 61% in 2003. Interest- ingly, the use of topical anesthesia appears to be The ability to lie still is critical.3 Therefore, condi- associated with the volume of cataract procedures tions such as the following might make a patient an performed. Those respondent surgeons performing inappropriate candidate for the block: involuntary one to five procedures per month used topical anes- movements/tremors,3,6,7 uncontrolled convulsive thesia in 38% of their cases while those doing more disorder,5 unpredictable and uncontrolled cough,6 than 75 procedures monthly used it 73% of the time. excessive anxiety and claustrophobia.5 Each anesthesia modality, however, has unique benefits and risks. Table 23 displays this information Patients should be older than 15 years, because young patients are not as likely to remain still for various anesthesia techniques used in ocular 5,6 surgery. throughout the block and surgical procedure. Like- wise, oriented patients, without significant mental Anesthesia 1985 1995 2000 2001 2003 impairment produced by psychiatric disorders or dementia, are more likely to stay still and follow in- Retrobulbar block with- 11% structions.3,5 Moreover, oriented patients are more out facial block likely to be able to understand and tolerate the ef- Retrobulbar block with 76% 32% 14% 9% fects of a retrobulbar block on eye movement and facial block vision during and for some time after surgery.3 Peribulbar block 38% 17% Topical Anesthesia 8% 51% 61% This article is reprinted from the PA-PSRS Patient Safety Advisory, Vol. 4, − 81% 73% with intracameral No. 1—March 2007. The Advisory is a publication of the Pennsylvania lidocaine Patient Safety Authority, produced by ECRI Institute & ISMP under contract − 1-5 cataract proce- 38% to the Authority as part of the Pennsylvania Patient Safety Reporting System dures/month (PA-PSRS). − more than 75 proce- 73% Copyright 2007 by the Patient Safety Authority. This publication may be dures/month reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. Table 1. Cataract Surgery Anesthesia Trends. Excerpted from Leaming DV. Practice styles and preferences of ASCRS To see other articles or issues of the Advisory, visit our Web site at members—2003 survey. J Cataract Refract Surg 2004;30: www.psa.state.pa.us. Click on “Advisories” in the left-hand menu bar. 892-900, with permission from Elsevier. ©2007 Pennsylvania Patient Safety Authority Page 1 Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 4, No. 1 (March 2007) Complications of Retrobulbar Blocks (Continued) Coagulation present.6,8 There must be enough room between This block is appropriate for patients with no signifi- the globe and the bony orbit to safely perform the cant bleeding or coagulation disorders.5 There is a block.7 Normal intraocular pressure and absence of difference of opinion concerning whether anticoagu- glaucoma are appropriate indications.6 The block lants, NSAIDS, aspirin, or clopidogrel bisulfate should not be completed if the globe is perforated.5,6 should be stopped prior to this block. One perspec- The patient must have no known allergy/cross sensi- tive is that patients receiving such medications are tivity to the local anesthetic to be used in the block.6 at greater risk of developing a retrobulbar hemor- rhage.8 Another perspective is that it is acceptable Co-morbidities to perform a retrobulbar block if the patient’s INR Because of the potential for significant complica- does not exceed twice the normal values.9 tions, patients who receive retrobulbar blocks should not be blind in the non-operated eye.6 Patients are Globe less likely to sustain a retrobulbar hemorrhage if Anatomical abnormalities (e.g., a myopic axial they do not have diseases that make the vascula- length greater than 26 to 32mm) should not be ture more fragile, such as acquired arteriosclerotic Anesthesia Benefits Risks General • Excellent anesthesia, analgesia, akinesia • Malignant hyperthermia • Duration of anesthesia can be varied to accommo- • Hemodynamic fluctuation date length of surgery • Postoperative nausea and vomiting • Allergic reactions • Increased risk of cardiac complications • Ocular complications: − pressure fluctuation − Valsava retinopathy − corneal abrasions − chemical injury • Requires more medication, equipment, personnel, therefore most costly form of anesthesia • Inefficiency: time required for induction, intubation, extubation Regional: • Excellent anesthesia, analgesia, akinesia • Patient may move, therefore not as controlled as general retrobulbar, peribulbar, • Duration of effect lasts for most cataract surgeries anesthesia sub-Tenon’s • Cost of medications and equipment less than • Localized swelling, bruising, subconjuntival hemorrhage general anesthesia • Allergic reactions • Injections take little time therefore more time- and • Brainstem anesthesia cost-efficient than general anesthesia • Ocularcardiac reflex • Blind injection into orbit: − retrobulbar hemorrhage − globe perforation − optic nerve damage • Eye movement and vision affected for some time after surgery − Peribulbar block • Decreased likelihood of optic nerve and global • Longer duration of onset perforation • Excellent akinesia and anesthesia − Sub-Tenon’s injection with • Lower risk of local complications blunt cannulas Topical • Most cost-and time-efficient • Rare local allergic reactions • Does not affect vision or motility therefore patients • Patients able to move eyes and other parts of the body may have improved and useful vision almost im- • Patient may perceive pain or pressure mediately after surgery • Patient may perceive visual phenomena • Minimal cosmetic changes • Avoids systemic risks of general anesthesia and risk of local trauma • Shortest duration of action Table 2. Benefits and Risks of Ocular Surgery Anesthesia Types. Excerpted from Navaleza JS, Pendse SJ, Blecher MH. Choosing anesthesia for cataract surgery. Ophthalmol Clin N Am 2006 Jun;19(2):233-7, with permission from Elsevier. Page 2 ©2007 Pennsylvania Patient Safety Authority Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 4, No. 1 (March 2007) Complications of Retrobulbar Blocks (Continued) vascular disease, hypertension, coronary artery dis- • The abducens nerve (VI), which regulates ease, peripheral or cerebral vascular disease, or 10 motor control to lateral rectus muscle. diabetes mellitus. • The oculomotor nerve (III), which regu- Length of Surgical Procedure lates motor control to all other extraocular Retrobulbar blocks may be appropriate if the surgi- muscles. cal procedure is expected to last less than 90 minutes.5 • The trochlear nerve (IV), which regulates motor control to superior oblique muscles. Anatomy To understand the technique of retrobulbar block All of these nerves except the trochlear pass and its complications, one must understand the through the retrobulbar muscle cone. As a result, eye’s basic anatomy and its relationship to sur- injecting a local anesthetic inside this cone provides rounding/supporting structures. anesthesia and akinesia of the globe, as well as the 1,7 1,7 extraocular muscles. The orbit is a pyramid-shaped cavity in the skull with a posterior apex and an anterior base. The orbit In addition to motor, sensory, and autonomic inner- is filled predominantly with adipose tissue, and the vation of the globe, there are many other structures globe (eyeball) is in the anterior portion of the cavity. within the retrobulbar muscle cone that can be at Four rectus muscles are attached around the equa- risk during retrobulbar injection including the optic tor of the globe. These muscles come together at the 7 nerve
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