Hilal AYOĞLU, Gamze KÜÇÜKOSMAN, Bengü Gülhan AYDIN, Özcan PİŞKİN, Bahar AKTAŞ, Rahşan Dilek OKYAY, Silay Cantürk UĞURBAŞ

Pediyatrik Şaşılık Cerrahisinde Okülokardiyak Refleks İnsidansını Etkileyen Faktörler: Retrospektif Çalışma

Amaç: Şaşılık cerrahisi sırasında okülokardiyak refleks (OKR) aktivasyonu yaygındır. OKR sinüs bradikardisi, atriyoventriküler blok, ventriküler fibrilasyon ve hatta asistol ile sonuçlanabilir. Pediyatrik hastalar bu refleksin zararlı etkilerine karşı daha savunmasızdır Bu çalışmada şaşılık cerrahisi geçiren pediyatrik hastalarda OKR insidansını etkileyen olası risk faktörlerini belirlemek amaçlandı. Yöntem: Ocak 2015-Eylül 2018 tarihleri arasında şaşılık cerrahisi geçiren pediyatrik hastaların kayıtları retrospektif olarak incelendi. Sadece tek bir cerrah tarafından yapılan ameliyatlar dahil edildi. OKR; ekstraoküler kas (EOK) manipülasyonunun neden olduğu kalp hızında %20’den fazla azalma olarak tanımlandı. Hastaların demografik verileri, cerrahi süre, önceden geçirilmiş şaşılık cerrahisi öyküsü, OKR gelişip gelişmediği, anestezi yönetimi; indüksiyon ve idamede kullanılan kas gevşeticiler ve anestezik ilaçlarının yanı sıra hava yolu yönetimi , opere edilen göz sayısı ve kas tipi kaydedildi. OKR için risk faktörleri lojistik regresyon analizi ile değerlendirildi. Bulgular: Başlangıçta değerlendirilen 92 pediyatrik hastadan, altısının dosyası eksik olduğu için çalışma dışı bırakıldı. Toplam 86 hasta çalışmaya dahil edildi. Ameliyat sırasında 29 hastada (%33.7) OKR görülmüştür. Pediyatrik hastalarda premedikasyonda benzodiyazepin (p=0.03) ve indüksiyon sonrası kas gevşetici uygulanmamış olması (p=0.046) bağımsız risk faktörleri olarak belirlenmiştir. Kas gevşetici kullanımının ve premedikasyonda benzodiyazepin uygulanmasının OKR riskini sırasıyla 3.64 ve 3.11 kat azalttığını bulduk. Sonuç: Şaşılık cerrahilerinde OKR insidansı kas gevşetici uygulanması, benzodiyazepin ile premedikasyon gibi önleyici tedbirlerle azaltılabilir

Factors Affecting Oculocardiac Reflex Incidence in Pediatric Strabismus Surgery: Retrospective Study

Objective: Oculocardiac reflex (OCR) activation is common during strabismus surgery. As a resultof OCR, sinus bradycardia, atrioventricular block, ventricular fibrillation and even asystole mayoccur. Pediatric patients are also more vulnerable to the harmful effects of this reflex. The aim ofthis study was to determine the possible risk factors affecting the incidence of OCR in pediatricpatients undergoing strabismus surgery.Method: The medical records of the pediatric patients who underwent strabismus surgerybetween January 2015 and September 2018 were retrospectively reviewed. The operations performed by the same surgeon were included in the study. OCR was defined as a more than 20%reduction in HR induced by the extraocular muscle (EOM) manipulation. Demographic data, duration of surgery, history of any previous strabismus surgery and possible development of OCR,anesthesia management, neuromuscular blocker and anesthetic drugs used for anesthesia induction and maintenance as well as airway management, the number of operated eyes, and also themuscle types of the patients were all recorded. Risk factors for OCR were evaluated by logisticregression analysis.Results: Out of 92 pediatric patients who were initially evaluated, six were excluded from thestudy because their files were missing. A total of 86 patients were included in the study. Duringsurgery, OCR occurred in 29 (33.7%) patients. The absence of administering benzodiazepine forpremedication (p=0.03) and nonuse of neuromuscular blocker after induction (p=0.046) in pediatric patients have been specified as independent risk factors. We found that the use of a neuromuscular blocker and benzodiazepine in premedication reduced the risk of OCR by 3.64 and 3.11times, respectively.Conclusion: The incidence of OCR may be reduced with preventive measures such as applicationof neuromuscular blocker, and premedication with benzodiazepine in strabismus surgeries.

PDF

___

1. Donlon JV, Doyle DJ, Feldman MA. Anesthesia for eye, ear, nose and throat surgery. In: Miller RD, (ed.) Miller’s anesthesia, Philadelphia, Churchill Livingstone 2006;2527-55.
2. Van Brocklin MD, Hirons RR, Yolton RL. The oculocardiac reflex: a review. J Am Optom Assoc. 1982;53:407- 13.
3. Lang SA, Van der Wal M. Death from the oculocardiac reflex. Can J Anaesth. 1994;41:161. https://doi.org/10.1007/BF03009813
4. Dewar KM. The oculocardiac reflex. Proc R Soc Med. 1976;69:373-4. https://doi.org/10.1177/003591577606900533
5. Rahimi Varposhti M, Moradi Farsani D, Ghadimi K, Asadi M. Reduction of oculocardiac reflex with Tetracaine eye drop in strabismus surgery. Strabismus. 2019;27:1-5. https://doi.org/10.1080/09273972.2018.1561732
6. Jean YK, Kam D, Gayer S, Palte HD, Stein ALS. Regional Anesthesia for Pediatric Ophthalmic Surgery: A Review of the Literature. Anesth Analg. 2020;130:1351-63. https://doi.org/10.1213/ANE.0000000000004012
7. Rodgers A, Cox RG. Anesthetic management for pediatric strabismus surgery: continuing professional development. Can J Anaesth. 2010;57:602-17. https://doi.org/10.1007/s12630-010-9300-x
8. Chung C, Lee J, Choi S, Lee S, Lee J. Effect of remifentanil on oculocardiac reflex in paediatric strabismus surgery. Acta Anaesthesiol Scand. 2008;52:1273-7. https://doi.org/10.1111/j.1399-6576.2008.01745.x
9. Oh A, Yun M, Kim H, Kim H. Comparison of desflurane with sevoflurane for the incidence of oculocardiac reflex in children undergoing strabismus surgery. Br J Anaesth. 2007;99:262-5. https://doi.org/10.1093/bja/aem145
10. Choi SR, Park SW, Lee JH, Lee SC, Chung CJ. Effect of different anesthetic agents on oculocardiac reflex in pediatric strabismus surgery. J Anesth. 2009;23:489-93. https://doi.org/10.1007/s00540-009-0801-0
11. Lai YH, Hsu HT, Wang HZ, Cheng KI. The oculocardiac reflex during strabismus surgery: its relationship to preoperative clinical eye findings and subsequent postoperative emesis. J AAPOS. 2014;18:151-5. https://doi.org/10.1016/j.jaapos.2013.11.024
12. Gilani SM, Jamil M, Akbar F, Jehangir R. Anticholinergic premedication for prevention of oculocardiac reflex during squint surgery. J Ayub Med Coll Abbottabad. 2005;17:57-9.
13. Ducloyer JB, Couret C, Magne C, et al. Prospective evaluation of anesthetic protocols during pediatric ophthalmic surgery. Eur J Ophthalmol. 2019;29:606-14. https://doi.org/10.1177/1120672118804798
14. Goto M, Nagashima M, Baba R, et al. Analysis of heart rate variability demonstrates effects of development on vagal modulation of heart rate in healthy children. J Pediatr. 1997;130:725-9. https://doi.org/10.1016/S0022-3476(97)80013-3
15. Karhunen U, Nilsson E, Brander P. Comparison of four non-depolarizing neuromuscular blocking drugs in the suppression of the oculocardiac reflex during strabismus surgery in children. Br J Anaesth. 1985;57:1209-12. https://doi.org/10.1093/bja/57.12.1209
16. Karanovic N, Jukic M, Carev M, Kardum G, Dogas Z. Rocuronium attenuates oculocardiac reflex during squint surgery in children anesthetized with halothane and nitrous oxide. Acta Anaesthesiol Scand. 2004;48:1301-5. https://doi.org/10.1111/j.1399-6576.2004.00523.x
17. Aranson JK. Meyler’s Side Effects of Drugs: The International Encyclopedia of Adverse Drug Reactions and Interactions, Elsevier Science. 2016; 231-5.
18. Kain ZN, Mayes LC, O’Connor TZ, Cicchetti DV. Preoperative anxiety in children. Predictors and outcomes. Arch Pediatr Adolesc Med. 1996;150:1238-45. https://doi.org/10.1001/archpedi.1996.02170370016002
19. Yi C, Jee D. Influence of the anaesthetic depth on the inhibition of the oculocardiac reflex during sevoflurane anaesthesia for paediatric strabismus surgery. Br J Anaesth. 2008;101:234-8. https://doi.org/10.1093/bja/aen129
20. Karaman T, Demir S, Dogru S, et al. The effect of anes- thesia depth on the oculocardiac reflex in strabismus surgery. J Clin Monit Comput. 2016;30:889-93. https://doi.org/10.1007/s10877-015-9789-1
21. Jeon S, Lee HJ, Do W, et al. Randomized controlled trial assessing the effectiveness of midazolam premedication as an anxiolytic, analgesic, sedative, and hemodynamic stabilizer. Medicine (Baltimore). 2018;97:e12187. https://doi.org/10.1097/MD.0000000000012187
22. Apt L, Isenberg S, GaffneyWL. The oculocardiac reflex in strabismus surgery. Am J Ophthalmol. 1973;76:533-6. https://doi.org/10.1016/0002-9394(73)90743-5
23. Tramer MR, Sansonetti A, Fuchs-Buder T, Rifat K. Oculocardiac reflex and postoperative vomiting in paediatric strabismus surgery. A randomised controlled trial comparing four anaesthetic techniques. Acta Anaesthesiol Scand. 1998;42:117-23. https://doi.org/10.1111/j.1399-6576.1998.tb05091.x
24. Blanc VF, Hardy JF, Milot J, Jacob JL. The oculocardiac reflex: a graphic and statistical analysis in infants and children. Can Anaesth Soc J. 1983;30:360-69. https://doi.org/10.1007/BF03007858
25. Stump M, Arnold RW. Iris color alone does not predict susceptibility to the oculocardiac reflex in strabismus surgery. Binocul Vis Strabismus Q. 1999;14:111-16.
26. Aletaha M, Bagheri A, Roodneshin F, Mosallaei M, Yazdani S. Oculocardiac Reflex during Strabismus Surgery: Experience from a Tertiary Hospital. Strabismus. 2016;24:74-8. https://doi.org/10.3109/09273972.2016.1170049
27. Ohashi T, Kase M, Yokoi M. Quantitative analysis of the oculocardiac reflex by traction on human extraocular muscle. Invest Ophthalmol Vis Sci. 1986;27:1160-64.
28. Ha SG, Huh J, Lee BR, Kim SH. Surgical factors affecting oculocardiac reflex during strabismus surgery. BMC Ophthalmol. 2018;18:103. https://doi.org/10.1186/s12886-018-0771-9
29. Arnold RW, Jensen PA, Kovtoun TA, Maurer SA, Schultz JA. The profound augmentation of the oculocardiac reflex by fast acting opioids. Binocul Vis Strabismus Q. 2004;19:215-22.
30. Ghai B, Ram J, Makkar JK, Wig J, Kaushik S. Subtenon block compared to intravenous fentanyl for perioperative analgesia in pediatric cataract surgery. Anesth Analg. 2009;108:1132-8. https://doi.org/10.1213/ane.0b013e318198a3fd
31. Ramachandran R, Rewari V, Chandralekha C, Sinha R, Trikha A, Sharma P. Sub-Tenon block does not provide superior postoperative analgesia vs intravenous fentanyl in pediatric squint surgery. Eur J Ophthalmol. 2014;24:643-9. https://doi.org/10.5301/ejo.5000438
32. Mirakhur RK, Shepherd WF, Jones CJ. Ventilation and the oculocardiac reflex. Prevention of oculocardiac reflex during surgery for squints: role of controlled ventilation and anticholinergic drugs. Anaesthesia. 1986;41:825-8. https://doi.org/10.1111/j.1365-2044.1986.tb13125.x