1Department of Anaesthesia and 2West of England Eye Unit, Royal Devon and Exeter Hospital, Barrack Road, Exeter EX2 5DW, UK*Corresponding author
Accepted for publication: January 10, 2002
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Abstract |
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Methods. In a randomized, double-blind study we compared the efficacy of 2% articaine with epinephrine 1:200 000 with a mixture of 0.5% bupivacaine and 2% lidocaine with epinephrine 1:200 000 for peribulbar anaesthesia in cataract surgery using a single inferotemporal injection. Eighty-two patients were randomly allocated to one of two groups to receive peribulbar anaesthesia with 67 ml of articaine or a bupivacaine/lidocaine mixture. Both solutions contained hyaluronidase 30 iu ml1. Ocular movement was scored at 2 min intervals up to 10 min, at the end of surgery and at time of discharge from hospital. Time to readiness for surgery and any complications (proptosis, chemosis, pain) were recorded.
Results. The articaine group demonstrated a rapid onset of peribulbar block with mean time (SD) to readiness for surgery of 4.2 (4.5) min compared with 7.2 (5.7) min in the bupivacaine/lidocaine group (P=0.0095). The block obtained in the articaine group was dense with eye movement scores at 2, 4, 6, 8 and 10 min all significantly reduced (P<0.01 at each interval). There was also a faster offset of the block in the articaine group (P=0.0009). There was no difference in incidence of minor complications between the groups.
Conclusions. Two per cent articaine is safe and effective for peribulbar anaesthesia by inferotemporal injection and is a suitable alternative to the traditional mixture of 0.5% bupivacaine and 2% lidocaine.
Br J Anaesth 2002; 88: 6768
Keywords: surgery, ophthalmological; anaesthetic techniques, regional, peribulbar; anaesthetics local, articaine
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Introduction |
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We have recently shown articaine to be superior to a standard mixture of 0.5% bupivacaine and 2% lidocaine for peribulbar anaesthesia using a single medial canthus technique.2 Although peribulbar block has been described by single medial canthus injection,35 the inferotemporal approach is used more commonly in the UK and is widely described both as a dual injection technique6 7 and as a single injection technique.8 9 In this study, we compared the effect of 2% articaine with 1:200 000 epinephrine and a traditional mixture of 0.5% bupivacaine and 2% lidocaine with 1:200 000 epinephrine using the more conventional inferotemporal approach for peribulbar anaesthesia.
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Methods |
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Patients were randomly allocated to one of two groups using sealed, numbered envelopes and computer randomization (Arcus Quickstat software, CamCode, Cambridge, UK). Group 1 received peribulbar anaesthesia using 2% articaine with epinephrine 1:200 000 and Group 2 received a mixture of equal volumes of 0.5% bupivacaine and 2% lidocaine with epinephrine 1:200 000. Hyaluronidase 30 iu ml1 was added to both solutions.
Patients were not fasted and did not receive any premedication. On arrival in the anaesthetic room, monitoring of arterial oxygen saturation, ECG, and non-invasive blood pressure was commenced. Intravenous access was secured and patients were given sedation upon request (alfentanil 125250 µg and midazolam 0.52 mg i.v.). Analgesia of the conjunctiva and cornea was provided by the topical administration of 0.4% oxybuprocaine drops. Peribulbar block was then performed by single inferotemporal injection by one of two consultant anaesthetists blinded to the local anaesthetic mixture. A 25 gauge 25 mm sharp disposable needle (BD Medical Systems, Drogheda, Ireland) was inserted inferolaterally and transconjunctivally past the equator of the globe then redirected upwards and inwards (1020°). After negative aspiration, 67 ml of local anaesthetic solution was injected. Digital massage was undertaken for 2 min. Eyeball movement was then assessed using the scoring system described by Brahma and colleagues3 at 2, 4, 6, 8 and 10 min. Ocular movements were 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 (Table 1).
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Statistical analysis was performed using Arcus Quickstat software. The Wilcoxon rank sum test was used to compare ocular movement scores. Students t-test was used for age, axial length, and volume of local anaesthetic and the 2 test for gender, supplementary injections, complications and visual acuity. P<0.05 was considered to be statistically significant for the Students t-test and
2 test, but P<0.01 was used for eye movement scores to avoid error from repeated statistical analysis.
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Results |
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Discussion |
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Whilst plain local anaesthetic solutions can be used for peribulbar anaesthesia, epinephrine-containing solutions are also commonly used to reduce systemic absorption and prolong local anaesthetic activity.10 11 Epinephrine may, however, cause problems of vasospasm in end arterioles, arrythmias following inadvertent intravascular injection and allergy to the metabisulphite preservative.12 We chose to use articaine with epinephrine as previous data suggested that the duration of action of plain articaine may not be sufficient for cataract surgery.1 We are now investigating the duration of action of plain articaine after sub-Tenon administration.
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Acknowledgements |
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References |
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2
Allman KG, McFadyen JG, Armstrong J, Sturrock GD, Wilson IH. Comparison of articaine and bupivacaine/lidocaine for single medial canthus peribulbar anaesthesia. Br J Anaesth 2001; 87: 5847
3 Brahma AK, Pemberton CJ, Ayeko M, Morgan LH. Single medial injection peribulbar anaesthesia using prilocaine. Anaesthesia 1994; 49: 10035[ISI][Medline]
4 Ripart J, Lefrant JY, Lalourcey L, et al. Medial canthus (caruncle) single injection periocular anaesthesia. Anesth Analg 1996; 83: 12348[Abstract]
5 Ripart J, Metge L, Prat PD, Lopez FM, Eledjam JJ. Medial canthus single-injection episcleral (sub-Tenon anaesthesia): computed tomography imaging. Anesth Analg 1998; 87: 425[Abstract]
6 Wong DHW. Regional anaesthesia for intraocular surgery. Can J Anaesth 1993; 40: 63557[Abstract]
7
Hamilton RC. Techniques of orbital anaesthesia. Br J Anaesth 1995; 75: 8892
8 McLure HA, Rubin AP. Comparison of 0.75% levobupivacaine with 0.75% racemic bupivacaine for peribulbar anaesthesia. Anaesthesia 1998; 53: 11604[ISI][Medline]
9
Mantovani C, Bryant AE, Nicholson G. Efficacy of varying concentrations of hyaluronidase in peribulbar anaesthesia. Br J Anaesth 2001; 86: 8768
10
Barr J, Kirkpatrick N, Dick A, Leonard L, Hawksworth G, Noble DW. Effects of adrenaline and hyaluronidase on plasma concentrations of lignocaine and bupivacaine after peribulbar anaesthesia. Br J Anaesth 1995; 75: 6927
11 Morsman CD, Holden R. The effects of adrenaline, hyaluronidase and age on peribulbar anaesthesia. Eye 1992; 6: 290292[ISI][Medline]
12 Schwartz HJ, Gilbert IA, Lenner KA, Sher TH, McFadden ER. Metabisulfite sensitivity and local dental anaesthesia. Ann Allergy 1989; 62: 836[ISI][Medline]