|Year : 2017 | Volume
| Issue : 1 | Page : 33-36
Efficacy of adding cisatracurium or rocuronium to the local anesthetic used for peribulbar anesthesia in patient undergoing cataract surgery
Reem A Sharkawy1, Tamer E Farahat1, Ehab H Nematallah2
1 Department of Anesthesia, Faculty of Medicine, Mansoura University, Mansoura, Egypt
2 Department of Ophthalmology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
|Date of Submission||20-Oct-2016|
|Date of Acceptance||20-Oct-2016|
|Date of Web Publication||24-May-2017|
Reem A Sharkawy
Department of Anesthesia, Faculty of Medicine, Mansoura University, Mansoura, 35516
Source of Support: None, Conflict of Interest: None
The peribulbar block (PBA) has been considered the sole of anesthetic of choice for cataract surgery. But it has a delayed onset of akinesia, which requires large volume of anesthetic solution and higher rate of supplementation when compared with retrobulbar anesthesia. We designed this study to evaluate the benefits of adding rocuronium and cisatracurium to PBA.
Patients and methods
In total, 60 patients were enrolled in this prospective randomized double-blind study and were subjected to cataract surgery. Patients were randomly divided into three groups equally: the first group (S) received PBA with 4-ml lignocaine 2%, 4-ml bupivacaine 0.5%, and hyaluronidase 30 IU/ml plus 0.5-ml normal saline. The second group (C) patients received 2.5-mg (0.5 ml) cisatracurium added to the standard local anesthetic mixture. The third group (R) patients received 5-mg (0.5 ml) rocuronium added to the standard local anesthetic mixture. The onset and duration of lid and globe akinesia were assessed.
The onset of lid and globe akinesia was significantly shorter in the cisatracurium group compared with the other two groups (P<0.001). The duration of both lid and globe akinesia was significantly longer in the rocuronium group than in the other groups (P<0.05). Regarding the need for supplementary block, it was lesser in the rocuronium group (5%) than in the cisatracurium group (10%) and the standard group (25%).
Adding muscle relaxant to the local anesthetic mixture (lidocaine, bupivacaine, and hyaluronidase) for PBA provides optimal globe akinesia, shortens the block onset time, and improves the postoperative analgesia.
Keywords: cataract surgery, cisatracurium, peribulbar anesthesia, rocuronium
|How to cite this article:|
Sharkawy RA, Farahat TE, Nematallah EH. Efficacy of adding cisatracurium or rocuronium to the local anesthetic used for peribulbar anesthesia in patient undergoing cataract surgery. Benha Med J 2017;34:33-6
|How to cite this URL:|
Sharkawy RA, Farahat TE, Nematallah EH. Efficacy of adding cisatracurium or rocuronium to the local anesthetic used for peribulbar anesthesia in patient undergoing cataract surgery. Benha Med J [serial online] 2017 [cited 2017 Sep 20];34:33-6. Available from: http://www.bmfj.eg.net/text.asp?2017/34/1/33/206899
| Introduction|| |
The local anesthesia involves blocking a group of nerves supplying a given part of the body by administration of local anesthetic drugs . Nowadays, it has been the standard method of anesthesia in ophthalmic surgery because of safety and high success rate , and also quick recovery of patients and decrease in hospital stay .
Retrobulbar and peribulbar blocks (PBA) are considered the two main approaches in eye surgery that can provide suitable conditions for intraocular surgeries either surgical or medical . The PBA provides optimal conditions for cataract surgery . However, PBA may have slower onset and/or incomplete orbital akinesia , so this necessitates another trial of block called block supplementation .
Many drugs have been added to the anesthetic solution to overcome these problems. Two of these agents are neuromuscular blocking agents atracurium  and vecuronium . The investigators concluded that these drugs not only improve the onset and duration of PBA but also reduce the use of postoperative analgesia. However, the main drawback of these drugs is the histamine-releasing property of atracurium which results in local hypermedia.
Rocuronium is a long-acting muscle relaxant and devoid of the activity of histamine release. Cisatracurium is another muscle relaxant that has a faster onset of action. Therefore, we designed this trial to examine the effects of these two different drugs on the quality of PBA.
Hypothesis and aim
The aim of the study is to compare between rocuronium and cisatracurium when added to local anesthesia for performing PBA in patients undergoing cataract extraction surgery.
| Patients and methods|| |
After obtaining approval of Local Ethics Committee of Mansoura University and an informed written consent from each patient, this prospective randomized double-blind study was conducted. In total, 60 patients of either sex were enrolled in this study. Inclusion criteria were as follows: patients with American Society of Anesthesiologists I-II, those whose age ranged from 50 to 80 years, and those who were scheduled for undergoing elective uncomplicated senile cataract surgery with intraocular lens implantation. Patients were excluded if they had a history of convulsion, epilepsy, presence of other ocular comorbidities such as exfoliation syndrome, uveitis myopia with axial length greater than 26 mm, hyperopia with axial length less than 21 mm, posterior synechia, phacodonesis, allergy to any of the study drugs, difficulty in communication, strabismus, or poor fixation owing to nystagmus.
The patients had been randomly allocated into three groups equally using opaque, sealed envelope method. The groups were based according to the type of the local anesthetic solution used. Each group had 20 patients. The patients in the first group S (study group) received the standard local anesthetic mixture alone (4-ml lignocaine 2%, 4-ml bupivacaine 5%, and hyaluronidase 30 IU/ml plus 0.5-ml saline) for peribulbar anesthesia. In the second group C (cisatracurium group), the patients received 2.5 mg (0.5 ml) of cisatracurium in addition to the standard local anesthetic mixture. Patients in the third group R (rocuronium group) received 5 mg (0.5 ml) of rocuronium in addition to the standard local anesthetic mixture.
Neither the anesthetist who had performed the PBA nor the patients were aware of the local anesthetic solution prepared.
In the anesthesia room, the patients were monitored using ECG, non invasive blood pressure (NIBP), and pulse oximetry, and oxygen was given via nasal cannula at 2 l/min. Patients received 2-3 drops of benoxinate hydrochloride 0.4% as topical anesthesia for the conjunctiva and cornea just before performing the block. An intravenous access was created.
The eyelid and periocular areas were cleaned with 5% povidone iodine. The patients were instructed to look straight ahead to ensure that the eye was in the neutral position of gaze. The injection was given at the inferotemporal site using a 1.25-inch but with blunt needle not sharp attached to 5-ml syringe containing the anesthetic agent, with the eye in neutral position of gaze. The needle was inserted through the lid as lateral as possible toward the junction of the inferior orbital rim and the lateral margin parallel to the floor of the orbit and tangential to the globe. The needle was advanced until the hub touched the skin. After negative aspiration for blood, 5 ml of lignocaine 2% mixed with adrenaline 1 : 200 000 (5 µg/ml) and hyaluronidase 150 IU/ml was injected. The eye was massaged digitally for 5–10 min.
Appropriate supplemental anesthetic injection was given through the medial canthal route to any participant in either group if needed.
Then peribulbar blockade was performed after the eyelid and periocular areas had been cleaned with 5% povidone iodine. The block had been done by two injections (infraorbital and medial orbital) utilizing a 25-mm 25-G needle. The degree of the akinesia had been categorized by the method described by Sarvela  as shown in [Table 1].
Akinesia of orbicularis muscle: 0, complete akinesia; 1, partial movement in either or both eyelid margins; 2, normal movement in either or both eyelid margins.
We assessed the onset and duration of akinesia, which means the absence of ocular movements in all four directions at 2, 5, and 10 min after the block. Then assessments were performed at 5-min intervals.
The block was considered to be satisfactory if there was a loss of at least two movements of the main four directions. If the condition was not adequate after 10 min of doing the block, supplemental injection with 2 ml of lidocaine 2% either medially or inferotemporally was given.
Arterial blood pressure, heart rate, and arterial oxygen saturation were checked before the block, then every 15 min during the entire procedure, and then every 30 min during the first two postoperative hours. Hypotension and bradycardia were defined as 20% or more decrease in the mean arterial blood pressure and heart rate compared with the preblock level.
Postoperative analgesia was assessed by using visual analogue scale from 0 to 10, where 0 means no pain and 10 means the worst imaginable pain, every 6 h postoperatively.
Any complications owing to the block were recorded, such as hematoma, retrobulbar hemorrhage, ecchymosis, ptosis, or diplopia.
Data were analyzed using statistical package for the social sciences (SPSS, US, version 15). Qualitative data were presented as numbers and percentage. Comparison between groups was done by χ2-test. Quantitative data were presented as mean±SD. Student t-test was used to compare between more than two groups. P less than 0.05 was considered to be statistically significant.
| Results|| |
In total, 60 patients were included in this prospective study. Of them, 33 patients were males and 27 were females, and the mean age of the patients was 63±65 years. As shown in [Table 2], there were no significant differences between the three studied groups regarding the demographic data and the operative time.
The onset of lid akinesia was found significantly shorter in group C than in groups R (P=0.001) and S (P<0.001), whereas no significant difference was found between groups S and R (P=0.078). Also the onset of globe akinesia was significantly shorter in group C than in the groups R (P=0.012) and S (P=0.004) as shown in [Table 3].
|Table 3 Onset and duration of lid and globe akinesia and duration of analgesia|
Click here to view
The patients in group R showed significantly longer duration of lid akinesia compared with the other groups. Also, the duration was found significantly longer in group C than in group S (P≤0.001). Similarly, the duration of globe akinesia and the duration of analgesia were found significantly longer in group R compared with the other two groups ([Table 3]).
Regarding the need for supplementary block, it was required in five (25%) cases, two (10%) cases, and one (5%) case of groups S, C, and R, respectively.
All patients were hemodynamically stable throughout the perioperative period. There were no adverse effects recorded among the studied groups.
| Discussion|| |
Using local anesthesia alone is not optimal regarding the onset and duration of lid and globe akinesia in cataract surgery. Therefore, many investigators have tried to add many drugs to improve the quality of anesthesia ,. Many neuromuscular blockers have been added to the local anesthetic drugs to improve the quality of PBA ,,.
We conducted this randomized, double-blinded prospective study to evaluate the benefits of adding two different types of muscle relaxant to the local anesthetic solution. In total, 60 patients were subjected to this trial and divided into three groups equally. We found that addition of cisatracurium resulted in shorter duration, whereas addition of rocuronium resulted in longer duration of the block. Moreover, both muscle relaxants had statistically longer duration for postoperative analgesia.
The results of this study match with those reported by Kucukyavuz and Arici  who concluded that the addition of 5-mg atracurium to a mixture of lidocaine 2% and bupivacaine 0.5% improved orbital akinesia and hastened onset time. However, they did not add hyaluronidase to the local anesthetic solution. Reah et al.  have also shown similar results when 0.5-mg vecuronium was added to a standard mixture of lidocaine 2% and bupivacaine 0.5%; however, they also added hyaluronidase 150 IU to their local anesthetic mixture. Recently, Aissaoui et al.  found that adding rocuronium 0.06 mg/kg to a local anesthetic mixture of 1% lidocaine and 0.25% bupivacaine improves the akinesia scores. However, our study differed from that of Aissaoui and colleagues, who used a variable dose based on body weight, by using a fixed low dose of rocuronium.
However, the mechanism through which nondepolarizing muscle relaxant improves orbital and lid akinesia is still not known, but it may be explained by the local effects of these drugs at the muscles’ motor endplate . Moreover, the extraocular muscles are extremely sensitive to the effect of neuromuscular blockers because the number of muscle fibers innervated by a single motor neuron is very small .
Regarding the duration of analgesia, our study showed progressive prolongation of the duration of analgesia between the standard group, cisatracurium group, and rocuronium group, and it was statistically significant. This in contrast to the study by Abdellatif et al.  who showed no statistically significant difference between rocuronium and control group regarding postoperative visual analogue scale.
We had chosen a small dose of muscle relaxant. It was less than one-tenth the dose needed for intubation. This was a safe dose .
| Conclusion|| |
For cataract surgery, the addition of low-dose cisatracurium to the standard local anesthetic solution accelerates the onset of akinesia. However, the addition of rocuronium prolongs the duration of the block.
Limitation of the study
There was no monitoring of neuromuscular blocking agents. So, we recommended further studies regarding this block with close neuromuscular monitoring to confirm the efficacy and safety of adding neuromuscular blocking drugs to the PBA (peribulbar block).
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Iganga ON, Fasina O, Bekibele CO, Ajayi BG, Oqundipe AO. Comparison of peribulbar with posterior sub-tenons anesthesia in cataract surgery among Nigerians. Middle East Afr J Ophthalmol 2016; 23:195–200.
] [Full text]
McLure HA, Rubin AP. Local anaesthesia for ophthalmic surgery. Curr Anaesth Crit Care 1999; 10: 40–47.
Malik A, Fletcher EC, Chong V, Dasan J. Local anaesthesia for cataract surgery. J Catarct Refract Surg 2010; 36:133–152.
Hamiliton RC, Gimbel HV, Strunin L. Regional anaesthesia for 12,000 cataract extraction and intraocular lens implantation procedures. Can J Anaesth 1988; 35:615–623.
Ripart J, Lefrant JY, de La Coussaye JE, Prat-Pradal D, Vivien B, Eledjam JJ. Peribulbar versus retrobulbar anesthesia for ophthalmic surgery: an anatomical comparison of extraconal and intraconal injections. Anesthesiology 2001; 94:56–62.
Wong DH. Regional anaesthesia for intraocular surgery. Can J Anaesth 1993; 40:635–657.
Loots JH, Koots AS, Venter JA. Peribulbar anesthesia. A prospective statistical analysis of the efficacy and predictability of bupivacaine and a lignocaine/bupivacaine mixture. J Cataract Refract Surg 1993; 19:72–76.
Kucukyavuz Z, Arici MK. Effects of atracurium added to local anesthetics on akinesia in peribulbar block. Reg Anesth Pain Med 2002; 27:487–490.
Reah G, Bodenham AR, Braitwaite P, Esmond J, Menage MJ. Peribulbar anaesthesia using a mixture of local anaesthesia and vecuronium. Anaesthesia 1998; 53:551–554.
Abdellatif AA, El Shahawy MA, Ahmed AI, Almarakbi WA, Alhashemi JA. Effects of local low-dose rocuronium on the quality of peribulbar anesthesia for cataract surgery. Saudi J Anaesth 2011; 5:360–364. [Full text]
Kestenbaum A. Clinical methods of neuro-ophthalmological examination. London: William Heinemann; 1947.
Sarvela PJ. Comparison of regional ophthalmic anesthesia produced by PH-adjusted 0.75% and 0.5% bupivacaine and 1% and 1.5% etidocaine, all with hyaluronidase. Anesth Analg 1993; 77:131–134.
Aissaoui Y, Belyamani L, Kamili ND. Effect of the addition of rocuronium to local anesthetics for peribulbar block. Act Anaesthesiol Belg 2010; 61:51–54.
[Table 1], [Table 2], [Table 3]