Letters to Editor Access this article online Quick response code Website: www.ijaweb.org
DOI: 10.4103/0019-5049.130854
Prevalence and indications of general anesthesia for adult cataracts in a tertiary care centre in India Sir, Current anesthesia options for cataract surgery include regional anesthesia (retrobulbar, peribulbar or sub‑tenon), topical anesthesia and general anesthesia. Though there are differences in the preferences, and practices of ophthalmic anesthesia,[1] regional or topical anesthesia are preferred modalities in adults. This study was conducted to evaluate the prevalence and indications of providing general anaesthesia for cataract surgery in adults at a tertiary care centre in northern India. A retrospective review of records of surgeries performed on patients presenting to the lens clinic at our tertiary care centre was done over a 10 year period from June 2003 to May 2012. Charts were reviewed for number of adults undergoing cataract surgery, type of anaesthesia administered, indications for surgery, age and gender. Patients requiring cardiopulmonary monitoring due to associated co‑morbidities who were operated under local anaesthesia were considered into local anaesthesia group. The total number of patients undergoing cataract surgery over the study period was 25,246 of which 2883 (11.42%) required general anaesthesia; 13 of these were adults (0.0514% of total; 0.45% of total general anaesthesia patients). Mean age of the patients was 23.07 years (range 17 to 35). Among these, 8 (61.53%) were males and 5 (38.46%) were females. The most common indication for using general anaesthesia was mental retardation in 61.55% (8/13), secondary to Down’s syndrome (3), cerebral palsy (2), congenital Indian Journal of Anaesthesia | Vol. 58 | Issue 2 | Mar-Apr 2014
rubella syndrome (1), tuberous sclerosis (1) and perinatal hypoxia (1). Other indications comprised of one case each of schizophrenia, seizure disorder, head nodding, nystagmus and hypersensitivity to local anesthetic agents (8.33% each). Advances in cataract surgery techniques have ushered in an era of regional ocular anaesthesia. Past evidence suggested absolute patient immobility with safety equivalent to local anaesthesia (LA) with general anaesthesia (GA).[2] However, with the advent of phacoemulsification, cataract surgery has become safer and faster, resulting in diminished need for absolute akinesia and anaesthesia. Complications like peri‑operative myocardial ischemia, pneumothorax, hormonal, metabolic and haemodynamic instability associated with GA in elderly patients undergoing cataract surgery have been reported.[3] Consequently, GA as well as retrobulbar block have largely been replaced with other means of LA.[3] The prevalence of GA for cataract surgery over 10 year period was 11.42%; majority of which was used for paediatric cataract and that for adults it was 0.05% in our setting. Chen et al.[4] reported a 3.71% prevalence of GA use in cataract surgery in United Kingdom, which is consistent with the 4.54% prevalence at Cataract National Dataset.[5] We found that GA in adults was mainly essential in cases of mental restrictions, uncontrolled neurological movements (involving head) and allergy to LA. Despite the higher costs and potential risks of GA, it may be indicated in the above conditions and these conditions should be looked into, both by the anaesthesiologists and ophthalmologists, before planning to take them for cataract surgery.
Sudarshan Khokhar, Shikha Gupta, Anasua Ganguly, Dilip Shende Department of Ophthalmology and Anaesthesiology, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India Address for correspondence: Dr. Shikha Gupta, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi - 110 029, India. E‑mail: [email protected]
REFERENCES 1.
2.
Eichel R, Goldberg I. Anaesthesia techniques for cataract surgery: A survey of delegates to the Congress of the International Council of Ophthalmology, 2002. Clin Experiment Ophthalmol 2005;33:469‑72. Campbell DN, Lim M, Muir MK, O’Sullivan G, Falcon M, 231
Letters to Editor Fison P, et al. A prospectiv e randomised study of local versus general anaesthesia for cataract surgery. Anaesthesia 1993;48:422‑8. 3. Navaleza JS, Pendse SJ, Blecher MH. Choosing anesthesia for cataract surgery. Ophthalmol Clin North Am 2006;19:233‑7. 4. Chen CK, Tseng VL, Wu WC, Greenberg PB. A survey on the use of general anaesthesia for cataract surgery. Graefes Arch Clin Exp Ophthalmol 2010;248:1051‑2. 5. Jaycock P, Johnston RL, Taylor H, Adams M, Tole DM, Galloway P, et al. The Cataract National Dataset electronic multicentre audit of 55,567 operations: Updating benchmark standards of care in the United Kingdom and internationally. Eye 2009;23:38‑49. Access this article online Quick response code Website: www.ijaweb.org
Figure 1: Upper lip angioedema DOI: 10.4103/0019-5049.130858
A rare case of angioedema after anaesthesia Sir, Angioedema is the acute onset swelling of skin or mucous membrane. Upper lip angioedema may herald life‑threatening upper airway oedema. A 57‑year‑old male weighing 50 kg was scheduled for direct laryngoscopy and biopsy of a laryngeal growth. He was a chronic smoker but non‑alcoholic. He was a known hypertensive on tablet ramipril 5 mg OD since 1 year. In the operating room, he was premedicated with glycopyrrolate 0.1 mg, midazolam 1 mg and fentanyl 100 µg intravenously. Anaesthesia was induced with propofol 100 mg and vecuronium 5 mg was administered for neuromuscular paralysis. The trachea was intubated and anaesthesia was maintained with 2% sevoflurane in a 50:50 mixture of O2 and N2O. Diclofenac 75 mg was given intravenously for post‑operative analgesia. At the end of the surgery, neuromuscular blockade was reversed with neostigmine 2.5 mg and glycopyrrolate 0.4 mg, the trachea extubated and the patient shifted to the post‑anaesthesia care unit. After 2 h, the patient developed swelling of the upper lip [Figure 1]. The skin over it was stretched, shiny and warm. There was no difficulty in swallowing or respiration. The tongue, lower lip, eyelids and oropharynx were normal. There was no associated urticaria or rash. On auscultation, there were no added 232
breath sounds. He had a pulse rate of 70/min, blood pressure 121/87 mm Hg, respiratory rate 14/min and SpO2 100%. He had no similar episode in the past and there was no family history of such oedema. There was no evidence of insect bite and he had not been allowed oral intake. A diagnosis of drug induced angioedema was made. The patient was given hydrocortisone 100 mg and pheniramine 45 mg intravenously. Adrenaline was kept ready. Ice packs were used to soothe the upper lip. He was continuously monitored for an increase in oedema or stridor. The swelling began to decrease in 2 h and completely subsided by 48 h. The patient had a history of previous uneventful ingestion of diclofenac. Hence, angiotensin converting enzyme inhibitor (ACEI) induced angioedema was diagnosed and ramipril was discontinued. He was started on tablet amlodipine for hypertension. He was educated about angioedema and its alerts and advised to abstain from alcohol and smoking. Recurrence of angioedema would have prompted sequential discontinuation of non‑steroidal anti‑inflammatory agents (NSAIDs), opioids and amlodipine with further investigation for hereditary and acquired angioedema. Angioedema may be idiopathic, extrinsic factor induced or due to C1 esterase inhibitor deficiency. It may be allergic (histamine mediated) or non‑allergic (kinin mediated). Drugs implicated include NSAID’s, ACEI and angiotensin receptor blockers.[1] The pathogenesis of ACEI induced angioedema is decreased degradation of bradykinin, causing vasodilation and increased vascular permeability, especially in the lax tissues of the face.[2] Tissue bradykinin is increased in all patients but angioedema occurs only in about 0.1‑0.7%.[1] ACEI have an Indian Journal of Anaesthesia | Vol. 58 | Issue 2 | Mar-Apr 2014
Copyright of Indian Journal of Anaesthesia is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
DOI: 10.4103/0019-5049.130854
Prevalence and indications of general anesthesia for adult cataracts in a tertiary care centre in India Sir, Current anesthesia options for cataract surgery include regional anesthesia (retrobulbar, peribulbar or sub‑tenon), topical anesthesia and general anesthesia. Though there are differences in the preferences, and practices of ophthalmic anesthesia,[1] regional or topical anesthesia are preferred modalities in adults. This study was conducted to evaluate the prevalence and indications of providing general anaesthesia for cataract surgery in adults at a tertiary care centre in northern India. A retrospective review of records of surgeries performed on patients presenting to the lens clinic at our tertiary care centre was done over a 10 year period from June 2003 to May 2012. Charts were reviewed for number of adults undergoing cataract surgery, type of anaesthesia administered, indications for surgery, age and gender. Patients requiring cardiopulmonary monitoring due to associated co‑morbidities who were operated under local anaesthesia were considered into local anaesthesia group. The total number of patients undergoing cataract surgery over the study period was 25,246 of which 2883 (11.42%) required general anaesthesia; 13 of these were adults (0.0514% of total; 0.45% of total general anaesthesia patients). Mean age of the patients was 23.07 years (range 17 to 35). Among these, 8 (61.53%) were males and 5 (38.46%) were females. The most common indication for using general anaesthesia was mental retardation in 61.55% (8/13), secondary to Down’s syndrome (3), cerebral palsy (2), congenital Indian Journal of Anaesthesia | Vol. 58 | Issue 2 | Mar-Apr 2014
rubella syndrome (1), tuberous sclerosis (1) and perinatal hypoxia (1). Other indications comprised of one case each of schizophrenia, seizure disorder, head nodding, nystagmus and hypersensitivity to local anesthetic agents (8.33% each). Advances in cataract surgery techniques have ushered in an era of regional ocular anaesthesia. Past evidence suggested absolute patient immobility with safety equivalent to local anaesthesia (LA) with general anaesthesia (GA).[2] However, with the advent of phacoemulsification, cataract surgery has become safer and faster, resulting in diminished need for absolute akinesia and anaesthesia. Complications like peri‑operative myocardial ischemia, pneumothorax, hormonal, metabolic and haemodynamic instability associated with GA in elderly patients undergoing cataract surgery have been reported.[3] Consequently, GA as well as retrobulbar block have largely been replaced with other means of LA.[3] The prevalence of GA for cataract surgery over 10 year period was 11.42%; majority of which was used for paediatric cataract and that for adults it was 0.05% in our setting. Chen et al.[4] reported a 3.71% prevalence of GA use in cataract surgery in United Kingdom, which is consistent with the 4.54% prevalence at Cataract National Dataset.[5] We found that GA in adults was mainly essential in cases of mental restrictions, uncontrolled neurological movements (involving head) and allergy to LA. Despite the higher costs and potential risks of GA, it may be indicated in the above conditions and these conditions should be looked into, both by the anaesthesiologists and ophthalmologists, before planning to take them for cataract surgery.
Sudarshan Khokhar, Shikha Gupta, Anasua Ganguly, Dilip Shende Department of Ophthalmology and Anaesthesiology, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India Address for correspondence: Dr. Shikha Gupta, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi - 110 029, India. E‑mail: [email protected]
REFERENCES 1.
2.
Eichel R, Goldberg I. Anaesthesia techniques for cataract surgery: A survey of delegates to the Congress of the International Council of Ophthalmology, 2002. Clin Experiment Ophthalmol 2005;33:469‑72. Campbell DN, Lim M, Muir MK, O’Sullivan G, Falcon M, 231
Letters to Editor Fison P, et al. A prospectiv e randomised study of local versus general anaesthesia for cataract surgery. Anaesthesia 1993;48:422‑8. 3. Navaleza JS, Pendse SJ, Blecher MH. Choosing anesthesia for cataract surgery. Ophthalmol Clin North Am 2006;19:233‑7. 4. Chen CK, Tseng VL, Wu WC, Greenberg PB. A survey on the use of general anaesthesia for cataract surgery. Graefes Arch Clin Exp Ophthalmol 2010;248:1051‑2. 5. Jaycock P, Johnston RL, Taylor H, Adams M, Tole DM, Galloway P, et al. The Cataract National Dataset electronic multicentre audit of 55,567 operations: Updating benchmark standards of care in the United Kingdom and internationally. Eye 2009;23:38‑49. Access this article online Quick response code Website: www.ijaweb.org
Figure 1: Upper lip angioedema DOI: 10.4103/0019-5049.130858
A rare case of angioedema after anaesthesia Sir, Angioedema is the acute onset swelling of skin or mucous membrane. Upper lip angioedema may herald life‑threatening upper airway oedema. A 57‑year‑old male weighing 50 kg was scheduled for direct laryngoscopy and biopsy of a laryngeal growth. He was a chronic smoker but non‑alcoholic. He was a known hypertensive on tablet ramipril 5 mg OD since 1 year. In the operating room, he was premedicated with glycopyrrolate 0.1 mg, midazolam 1 mg and fentanyl 100 µg intravenously. Anaesthesia was induced with propofol 100 mg and vecuronium 5 mg was administered for neuromuscular paralysis. The trachea was intubated and anaesthesia was maintained with 2% sevoflurane in a 50:50 mixture of O2 and N2O. Diclofenac 75 mg was given intravenously for post‑operative analgesia. At the end of the surgery, neuromuscular blockade was reversed with neostigmine 2.5 mg and glycopyrrolate 0.4 mg, the trachea extubated and the patient shifted to the post‑anaesthesia care unit. After 2 h, the patient developed swelling of the upper lip [Figure 1]. The skin over it was stretched, shiny and warm. There was no difficulty in swallowing or respiration. The tongue, lower lip, eyelids and oropharynx were normal. There was no associated urticaria or rash. On auscultation, there were no added 232
breath sounds. He had a pulse rate of 70/min, blood pressure 121/87 mm Hg, respiratory rate 14/min and SpO2 100%. He had no similar episode in the past and there was no family history of such oedema. There was no evidence of insect bite and he had not been allowed oral intake. A diagnosis of drug induced angioedema was made. The patient was given hydrocortisone 100 mg and pheniramine 45 mg intravenously. Adrenaline was kept ready. Ice packs were used to soothe the upper lip. He was continuously monitored for an increase in oedema or stridor. The swelling began to decrease in 2 h and completely subsided by 48 h. The patient had a history of previous uneventful ingestion of diclofenac. Hence, angiotensin converting enzyme inhibitor (ACEI) induced angioedema was diagnosed and ramipril was discontinued. He was started on tablet amlodipine for hypertension. He was educated about angioedema and its alerts and advised to abstain from alcohol and smoking. Recurrence of angioedema would have prompted sequential discontinuation of non‑steroidal anti‑inflammatory agents (NSAIDs), opioids and amlodipine with further investigation for hereditary and acquired angioedema. Angioedema may be idiopathic, extrinsic factor induced or due to C1 esterase inhibitor deficiency. It may be allergic (histamine mediated) or non‑allergic (kinin mediated). Drugs implicated include NSAID’s, ACEI and angiotensin receptor blockers.[1] The pathogenesis of ACEI induced angioedema is decreased degradation of bradykinin, causing vasodilation and increased vascular permeability, especially in the lax tissues of the face.[2] Tissue bradykinin is increased in all patients but angioedema occurs only in about 0.1‑0.7%.[1] ACEI have an Indian Journal of Anaesthesia | Vol. 58 | Issue 2 | Mar-Apr 2014
Copyright of Indian Journal of Anaesthesia is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
