1 Department of Ophthalmology and 2 Department of Anaesthesiology, Medical Faculty of Kahramanmaras Sutcu Imam University, T-46050 Kahramanmaras, Turkey
*Corresponding author. E-mail: drmozdemir@hotmail.com
Accepted for publication: July 7, 2003
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Abstract |
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Method. In this double-blind randomized clinical study, 58 cataract patients were allocated to receive either articaine 2% with epinephrine 1:200 000 or a mixture of equal parts of lidocaine 2% with epinephrine 1.25:100 000 and bupivacaine 0.5%. Ocular and eyelid movement scores, the number of supplementary injections, total volume of solution used and pain and complications during injection and surgery were used as clinical end-points.
Results. Articaine produced greater akinesia after 5 min (P=0.03). Eighteen patients (60%) in the articaine group and 26 (93%) in the lidocaine/bupivacaine group required a second injection (P=0.003). A third injection was needed by two patients (7%) in the articaine group and 12 (43%) in the lidocaine/bupivacaine group (P=0.001). The total mean volume of local anaesthetic required to achieve akinesia was mean 9.4 (SD 1.7) ml in the articaine group and 11.28 (1.86) ml in the lidocaine/bupivacaine group (P<0.001). Median pain score was lower in the articaine group than in lidocaine/bupivacaine group during injection (P=0.004) and surgery (P=0.014). There was no difference between the groups for the incidence of complications.
Conclusion. Articaine 2% without hyaluronidase is more advantageous than a mixture of lidocaine 2% and bupivacaine 0.5% without hyaluronidase for peribulbar anaesthesia in cataract surgery.
Br J Anaesth 2004; 92: 2314
Keywords: anaesthetic techniques, regional, peribulbar; anaesthetics local, articaine; anaesthetics local, lidocaine/bupivacaine combination; enzymes, hyaluronidase
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Introduction |
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Articaine, an amide local anaesthetic, was first investigated in 1974.5 Currently, it is used for dental surgery in most European countries. Features such as low toxicity, quick diffusion and rapid clearance have led to its widespread use.6 Recently, two reports have described the use of articaine in peribulbar anaesthesia.7 8
In this study we compared the safety and efficacy of articaine 2% with a lidocaine 2%/bupivacaine 0.5% mixture, without hyaluronidase.
Patients and methods
Local medical ethics committee approval for the study was obtained and all patients gave informed consent. Fifty-eight patients undergoing cataract surgery under local anaesthesia were included in the study. Communication problems, history of allergy to amide-type local anaesthetic agents, low plasma cholinesterase activity (possibly leading to reduced metabolism of articaine) were exclusion criteria.
Patients were allocated randomly to receive either articaine 2% with 1:200 000 epinephrine (Ultracaine, Hoechst Marion Roussel, Germany) (n=30) or a mixture of bupivacaine 0.5%, 5 ml (Marcaine flc, Eczacibasi, Turkey) and lidocaine 2%, 5 ml with 1.25:100 000 epinephrine (Jetocaine amp, Adeka, Turkey) (n=28).
Randomization was performed using statistical tables. Allocation was undertaken using sealing envelopes, which were handed over to a resident not involved in the study, who then drew up the local anaesthetic mixture and handed the unlabelled syringe to the investigator. Before surgery, all patients were examined and routine laboratory investigations were performed. Patients were premedicated with oral diazepam at 6 a.m. on the day of surgery.
On arrival in the anaesthetic room, a vein was cannulated and arterial pressure was measured with an automated oscillometer, and monitoring of arterial oxygen saturation and the ECG was commenced. Topical anaesthesia of the conjunctiva and cornea was provided by administering oxibuprocaine 0.4% drops, twice within 2 min. One of two surgeons, who were blinded to the local anaesthetic used, performed local anaesthesia and scored the progression of akinesia. Peribulbar anaesthesia was performed by transpalbepral injection at the third lateral of the inferior eyelid. The needle was introduced along the inferior wall of the orbit to a depth of 2025 ml with the sharp bevel facing the globe. The direction of injection was almost perpendicular to the frontal plane and parallel to the sagittal plane; the eye was in the neutral position. Injection was performed step by step: into the eyelid (0.5 ml), right after the eyelid (1 ml), at the equator (2 ml) and then behind the equator (2.5 ml). Injections were performed after gentle negative aspiration. Local anaesthetic was injected using a 22 mm, 25 G peribulbar Atkinson needle (Visitec 5027). The maximum injection volume was 8 ml and injection was stopped if proptosis developed. Gentle digital massage of the eyeball between scoring facilitated diffusion of local anaesthetic.
Patients were evaluated for ocular and eyelid movements at 1, 5 and 10 min after injection, at the end of the surgery and before discharge from hospital on the same day, using the scoring system of Brahma and colleagues.3 Ocular movement was scored for each direction of gaze in the superior, inferior, medial and lateral directions, with a maximum score for each direction of 3 points and a possible total maximum of 12 points. The scoring system for eyelid movements is shown in Table 1.
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Statistical analysis of data was performed using Epi Info 2002 (CDC) software. The MannWhitney U-test was used to compare ocular and eyelid movement scores, and pain score. The two-tailed Students t-test was used for age, total volume of local anaesthetic, duration of surgery and time from initial injection to the end of surgery. The 2-test or Fishers exact test, as appropriate, was used for sex, number of supplementary injections required and complications.
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Results |
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The ocular movement score was significantly lower in the articaine group at all evaluation points (Table 2). Eighteen patients (60%) in the articaine group and 26 (93%) in the lidocaine/bupivacaine group required second injections (P=0.003) (Fig. 1). Two patients (7%) in the articaine group and 12 (43%) in the lidocaine/bupivacaine group required a third injection (P=0.001).
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The total volume of local anaesthetic solution used was 9.47 (1.7) ml and 11.8 (1.9) ml in the articaine group and lidocaine/bupivacaine group, respectively (CI 2.7 to 0.9 ml, P<0.001).
Local anaesthesia complications were the same in both groups (P>0.05). Chemosis during injection developed in three patients in the articaine group and five in the lidocaine/bupivacaine group. A small periorbital haematoma occurred in one patient in the lidocaine/bupivacaine group; no other local anaesthesia complications such as retro-orbital haematoma or globe perforation was observed.
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Discussion |
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A single injection for peribulbar anaesthesia has several advantages over multiple injections. Single injection decreases the pain, risk of globe perforation, haemorrhage and intravascular injection. Additional injections increase the complication risk.
In our study, the articaine group had fewer requirements for a second injection (60%); the need for a third injection rate was also less in this group. This superior action of articaine may be related to better tissue diffusion. Almann and colleagues7 reported a second injection rate of 24% for articaine 2% with hyaluronidase and 51% for bupivacaine/lidocaine with hyaluronidase. There was no need for a third injection in the articaine group and one patient needed a third injection in the lidocaine/bupivacaine group. Require ments for additional injections were less in Allmans studies7 8 than in our study. This is probably related to the use of hyaluronidase.
In the present study, the complication rate was similar in both groups. Allman and colleagues7 found a higher frequency of complications in the lidocaine/bupivacaine group compared with the articaine group. However, in a second study on articaine,8 they did not demonstrate any significant differences between articaine and lidocaine/bupivacaine.
In our study, there was no reduction in anaesthetic effect during surgery. However, at discharge from hospital, both globe movement score and eyelid movement score were significantly higher in the articaine group.
One of the most unpleasant aspects of local anaesthesia is pain during surgery. Many patients delay surgery because of fear of pain and the injection. In our study, patients in the articaine group had lower pain scores during injection and surgery.
In conclusion, this study suggests that articaine 2% (with epinephrine 1:200 000) without hyaluronidase has several advantages over lidocaine 2% with 1.25:100 000 epineprhine and bupivacaine 0.5% without hyaluronidase for peribulbar anaesthesia in cataract surgery.
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References |
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