Phacoemulsification under Topical Anesthesia in a Tertiary Care Hospital

Introduction: The use of topical anaesthesia for cataract surgery dates back to 1884 when Knapp used 5% cocaine to anaesthetize cornea. The advancement in cataract surgery techniques like small stepped, self-sealing corneal incisions, phacoemulsification and advanced intraocular lenses has allowed the use of topical anaesthesia thus reducing surgical time and need of akinesia. Materials and Methods: Prospective non-comparative evaluation of patients’ and surgeon’s satisfaction under topical anaesthesia. All patients received topical anesthesia with proparacaine 0.5%. A 10-point visual analogue scale was given to patients to rate the level of pain felt during the operation. Also, the level of patient satisfaction, the need for supplemental anaesthesia, level of ocular motility, surgical complications and postoperative visual acuity were recorded. Results: Total number of cases were 156 out of which 86 (55.1%) were males and 70 (44.9%) were females. Nuclear sclerosis was most common type of cataract followed by mixed opacities. Majority of patients had no intraoperative movement and 30.8% of patients had some movement. Surgeon was dissatisfied in only 12.2% cases who had disturbing movements during surgery. Although majority of patients felt no pain (68%) or mild pain (23.7%) during surgery 8.3% cases had moderate to severe pain which required supplemental intracameral lidocaine. Conclusion: Topical anaesthesia is cost effective, provides high patient comfort during surgery, is less stressful for the patient, saves considerable time and complications compared to regional anaesthesia. Keywords: topical anaesthesia, phacoemulsification, pain assessment, surgeon`s satisfaction.

Utilization of Pleth Index in Hysteroscopic Surgery: A Randomized Controlled Trial

Background: When performing hysteroscopic surgery under general anesthesia in non-intubated patients, anesthesiologists and gynecologists face challenges including patient movement and respiratory depression due to variability in the depth of patient anesthesia. Intraoperative modulation of the depth of anesthesia is dictated by clinical practice. In recent years, the noninvasive surgical pleth index (SPI) has been purported to objectively reflect the depth of anesthesia. In the present study, we investigated the performance of SPI monitoring in hysteroscopic surgery.Methods: Eighty patients scheduled for hysteroscopic surgery under general anesthesia with a laryngeal mask airway (i.e., spontaneous ventilation without a muscle relaxant) were randomly divided into two groups (both n = 40): (1) bispectral index (BIS)- and SPI-monitoring group (BS Group); and (2) BIS-monitoring group (B group). Intraoperative analgesia was provided via target-controlled infusion (TCI) of remifentanil, which was modulated according to the SPI value (target interval, 20–50) in the BS Group or via the anesthesiologist's assessment in the B Group. In both groups, anesthesia was administered to maintain the BIS values between 40–60. Additionally, the incidences and degree of movement, consumption of anesthetic drugs, recovery times, complications, and satisfactory levels were compared between the two groups.Results: The incidence and degree of bodily movement in the BS Group were significantly lower than those in the B Group (P < 0.05). Furthermore, the remifentanil induction dose and recovery time in the BS group were significantly lower than those in the B group (P < 0.05). However, there were no significant differences between the two groups with regard to adverse events including nausea, vomiting, and dizziness. Finally, gynecologists had higher satisfactory levels in the BS Group (P < 0.05).Conclusion: SPI- and BIS-guided general anesthesia is clinically feasible in hysteroscopic surgery and leads to both inhibition of intraoperative movement and faster recovery.

Undetected Intraoperative Pelvic Movement Can Lead to Inaccurate Acetabular Cup Component Placement during Total Hip Arthroplasty: A Mathematical Simulation Estimating Change in Cup Position

Intraoperative patient movement is a common but underappreciated phenomenon in total hip arthroplasty (THA). Such movement can significantly affect the accuracy with which the acetabular cup component is implanted. To evaluate the effect of intraoperative movement on cup position, we performed a study using mathematical modeling to simulate intraoperative movement. Mathematical simulations were used to simulate pelvic movements during THA. Pelvic axial rotation, tilt, and obliquity were simulated, and the resulting changes in intended cup position were calculated. The rate of change of inclination and anteversion per degree of pelvic movement was calculated, establishing a ratio relating cup angle sensitivity to pelvic movement. These sensitivities were used to construct nomograms showing the per-degree effect of pelvic movement on cup position. The effect of pelvic movement on cup position was multifactorial and dependent on the intended cup orientation. For a cup intended to be inserted at 15° anteversion and 40° inclination, each degree of pelvic rotation induced changes of 0.64° and –0.20°, respectively. For this same cup orientation, each degree of pelvic tilt induced changes of 0.77° for anteversion and 0.17° for inclination. Pelvic obliquity was associated with a 1:1 ratio with inclination, with each degree of obliquity inducing 1° of change in inclination. Anteversion was unaffected by changes in pelvic obliquity. This study demonstrates the consequences of undetected pelvic movement on cup position, including the increased risk of the acetabular component being placed in an orientation that could increase wear or the likelihood of impingement and dislocation.

Remifentanil-based anesthesia versus a propofol technique for otologic surgical procedures

Otologic procedures require a still surgical field and are associated with a 50% incidence of emetic symptoms. Propofol reduces nausea and vomiting but not intraoperative movement. This study compares a remifentanil/propofol anesthetic to a propofol/fentanyl combination to determine which provides the best perioperative conditions for otologic microsurgery. Eighty healthy patients were randomly assigned to receive one of the anesthetic combinations. Demographic data, hemodynamic variables, movement, and bispectral index monitoring values in addition to anesthetic emergence, nausea, vomiting, pain, and other recovery variables were compared between groups with appropriate statistical methods. Both groups were similar. Times to eye opening (7.7 ± 0.7 vs 12.4 ±1.2 minutes) and extubation (9.8 ± 0.9 vs 12.4 ±1.0 minutes) were shorter with remifentanil. This group also had lower hemodynamic variables and movement (23% vs 65%) under anesthesia. Postoperative pain was mild in both groups, but remifentanil patients had more than the propofol group. All other postoperative parameters were similar. Remifentanil-based anesthesia produces better hemodynamic stability, less movement, and faster emergence after otologic surgery, with propofol's antiemetic effect, for the same cost.