Vol. 114, No. 5
Letters to The Journal
Propofol and Surgical Contamination in Strabismus Surgery Dorothy V. Bautista, M.D., F.R.C.S.(C), and Ronald V. Keech, M.D. Department of Ophthalmology, University of Iowa Hospitals and Clinics. Inquiries to Ronald V. Keech, M.D., Department of Ophthalmology, University of Iowa Hospitals and Clinics, Iowa City, IA 52246. Propofol (diprivan-ICI) is a short-acting in travenous hypnotic agent used for the induc tion and maintenance of general anesthesia. Propofol has become popular for outpatient surgery because of the shorter recovery period, compared with that of other general anesthe tics.1,2 We have found propofol to be useful as an anesthetic agent for strabismus surgery, es pecially when adjustable sutures are used. Common adverse effects of propofol include hypotension, nausea, and burning at the ad ministration site. A less common adverse effect is hypersalivation. This effect can be potentially detrimental in strabismus surgery because of the close proximity of the operative site to the patient's mouth and nose. Since the introduc tion of propofol for use in the ambulatory surgical center of our institution, we have noted an increased incidence of oral and nasal secre tions in our patients during surgery that, in some cases, has resulted in contamination of the operative field. A 35-year-old man underwent a re-operation for exotropia. Anesthesia was induced with propofol and fentanyl. Intubation was per formed by using atracurium. Maintenance of anesthesia was achieved with nitrous oxide, oxygen, and propofol. The patient was pre pared and draped, leaving the eyes exposed. An occlusive plastic drape was placed at the edge of the towel drape to form a seal between the patient's skin and the towels. After approxi mately one hour of surgery, nasal secretions were seen penetrating the surgical drapes and entering the operative field. The area was im mediately irrigated with saline, the drapes re moved, and nasal secretions aspirated. Nasal packing was inserted into the nostrils. The surgical site was prepped and draped again and the eye irrigated with an ophthalmic antibiotic solution. At the end of the procedure, an antibi otic ointment was instilled into the conjunctival sac. There were no postoperative complica tions.
635
A 5%-year-old boy underwent strabismus surgery for esotropia. Anesthesia was induced with halothane and maintained with propofol, nitrous oxide, and oxygen. Intubation was per formed by using atracurium and glycopyrrolate. The patient was prepared and draped, leaving the eyes exposed. An adhesive plastic drape was used to form an occlusive seal be tween the patient's skin and the towels. Upon completion of the operative procedure, during closure of the conjunctival peritomy of the second operated-on eye, oral and nasal secre tions were seen leaking through the drapes and contaminating the operative field. The eye was irrigated with normal saline, and a subconjunctival injection of cefazolin was administered. Antibiotic ointment was instilled into the con junctival sac of both eyes. There were no post operative complications. We have had two additional cases where the cloth drapes adjacent to the operative field were saturated with nasal secretions. In both cases, the drapes were changed before the operative field became contaminated. The cause of excessive oral and nasal secre tions in these cases is unknown. In our experi ence, this complication appears to be more likely in adult patients undergoing relatively long procedures. We have used anticholinergic agents as well as nasal packing with limited success in reducing secretions. Other anesthet ic agents may contribute to the increased secre tions. However, we believe propofol is the most likely causative agent. Neither of us has seen this complication when propofol was not used. Propofol is well known to increase secretions, although the mechanism remains unclear. Sur geons who operate near the patient's nose or mouth should be aware of this potential com plication.
References 1. Larsson, S., Asgeirsson, B., and Magnusson, J.: Propofol-fentanyl anesthesia compared to thiopental-halothane with special reference to recovery and vomiting after pediatrie strabismus surgery. Acta Anaesth. Scand. 36:182, 1992. 2. Valtonen, M., Kanto, J., and Klossner, J.: Anaes thesia for cardioversion. A comparison of propofol and thiopentone. Can. J. Anaesth. 36:479, 1988.
Letters to The Journal
Propofol and Surgical Contamination in Strabismus Surgery Dorothy V. Bautista, M.D., F.R.C.S.(C), and Ronald V. Keech, M.D. Department of Ophthalmology, University of Iowa Hospitals and Clinics. Inquiries to Ronald V. Keech, M.D., Department of Ophthalmology, University of Iowa Hospitals and Clinics, Iowa City, IA 52246. Propofol (diprivan-ICI) is a short-acting in travenous hypnotic agent used for the induc tion and maintenance of general anesthesia. Propofol has become popular for outpatient surgery because of the shorter recovery period, compared with that of other general anesthe tics.1,2 We have found propofol to be useful as an anesthetic agent for strabismus surgery, es pecially when adjustable sutures are used. Common adverse effects of propofol include hypotension, nausea, and burning at the ad ministration site. A less common adverse effect is hypersalivation. This effect can be potentially detrimental in strabismus surgery because of the close proximity of the operative site to the patient's mouth and nose. Since the introduc tion of propofol for use in the ambulatory surgical center of our institution, we have noted an increased incidence of oral and nasal secre tions in our patients during surgery that, in some cases, has resulted in contamination of the operative field. A 35-year-old man underwent a re-operation for exotropia. Anesthesia was induced with propofol and fentanyl. Intubation was per formed by using atracurium. Maintenance of anesthesia was achieved with nitrous oxide, oxygen, and propofol. The patient was pre pared and draped, leaving the eyes exposed. An occlusive plastic drape was placed at the edge of the towel drape to form a seal between the patient's skin and the towels. After approxi mately one hour of surgery, nasal secretions were seen penetrating the surgical drapes and entering the operative field. The area was im mediately irrigated with saline, the drapes re moved, and nasal secretions aspirated. Nasal packing was inserted into the nostrils. The surgical site was prepped and draped again and the eye irrigated with an ophthalmic antibiotic solution. At the end of the procedure, an antibi otic ointment was instilled into the conjunctival sac. There were no postoperative complica tions.
635
A 5%-year-old boy underwent strabismus surgery for esotropia. Anesthesia was induced with halothane and maintained with propofol, nitrous oxide, and oxygen. Intubation was per formed by using atracurium and glycopyrrolate. The patient was prepared and draped, leaving the eyes exposed. An adhesive plastic drape was used to form an occlusive seal be tween the patient's skin and the towels. Upon completion of the operative procedure, during closure of the conjunctival peritomy of the second operated-on eye, oral and nasal secre tions were seen leaking through the drapes and contaminating the operative field. The eye was irrigated with normal saline, and a subconjunctival injection of cefazolin was administered. Antibiotic ointment was instilled into the con junctival sac of both eyes. There were no post operative complications. We have had two additional cases where the cloth drapes adjacent to the operative field were saturated with nasal secretions. In both cases, the drapes were changed before the operative field became contaminated. The cause of excessive oral and nasal secre tions in these cases is unknown. In our experi ence, this complication appears to be more likely in adult patients undergoing relatively long procedures. We have used anticholinergic agents as well as nasal packing with limited success in reducing secretions. Other anesthet ic agents may contribute to the increased secre tions. However, we believe propofol is the most likely causative agent. Neither of us has seen this complication when propofol was not used. Propofol is well known to increase secretions, although the mechanism remains unclear. Sur geons who operate near the patient's nose or mouth should be aware of this potential com plication.
References 1. Larsson, S., Asgeirsson, B., and Magnusson, J.: Propofol-fentanyl anesthesia compared to thiopental-halothane with special reference to recovery and vomiting after pediatrie strabismus surgery. Acta Anaesth. Scand. 36:182, 1992. 2. Valtonen, M., Kanto, J., and Klossner, J.: Anaes thesia for cardioversion. A comparison of propofol and thiopentone. Can. J. Anaesth. 36:479, 1988.
