|Year : 2021 | Volume
| Issue : 1 | Page : 38-39
Ropivacaine 0.75% for peribulbar block in vitrectomy
Tjokorda Gde Agung Senapathi1, I Made Gede Widnyana1, Christopher Ryalino1, Ida Bagus Gita Dharma Wibawa2
1 Department of Anaesthesiology and Intensive Care, Faculty of Medicine, Udayana University, Denpasar, Bali, Indonesia
2 Department of Anesthesiology, Pain Management and Intensive Care, Sanglah General Hospital, Udayana University, Denpasar, Bali, Indonesia
|Date of Submission||15-Jul-2020|
|Date of Decision||11-Oct-2020|
|Date of Acceptance||20-Oct-2020|
|Date of Web Publication||8-Feb-2021|
Dr. Christopher Ryalino
Department of Anaesthesiology and Intensive Care, Faculty of Medicine, Udayana University, Jl. PB Sudirman, Denpasar 80232, Bali
Source of Support: None, Conflict of Interest: None
Increased life expectancy will result in an increased number of elderlies scheduled for surgery. The vitreous undergoes the irreversible process of aging. Anesthesiologists must provide optimal perioperative care for patients posted for vitrectomy. Peribulbar block is one of the safest alternatives. Ropivacaine has a vasoconstriction effect that useful to minimize the increasing of intraocular pressure (IOP) after peribulbar injection. In this case report, we managed an 86-year-old patient who underwent vitrectomy procedure by peribulbar block. Peribulbar block provides blocks for ciliary, oculomotor, and abducens nerves. The needle is introduced into the extraconal space. The first injection is inferior and temporal, and the second injection is superior and nasal, between the medial third and lateral two-thirds of the orbital roof. The block provided adequate analgesia, akinesia, and decreased IOP.
Keywords: Akinesia, bupivacaine, peribulbar, ropivacaine
|How to cite this article:|
Agung Senapathi TG, Gede Widnyana I M, Ryalino C, Gita Dharma Wibawa IB. Ropivacaine 0.75% for peribulbar block in vitrectomy. Bali J Anaesthesiol 2021;5:38-9
|How to cite this URL:|
Agung Senapathi TG, Gede Widnyana I M, Ryalino C, Gita Dharma Wibawa IB. Ropivacaine 0.75% for peribulbar block in vitrectomy. Bali J Anaesthesiol [serial online] 2021 [cited 2021 Mar 1];5:38-9. Available from: https://www.bjoaonline.com/text.asp?2021/5/1/38/308881
| Introduction|| |
The medical revolution these latest decades gives so much impact to surgery and anesthesia, especially on the elderly. Increased life expectancy in elderly patient, which will undergo operation, medical team need to improve methods to get a better outcome. Previous studies have underlined the prevalence of visual impairment in Asian countries.,,,
The peribulbar block is one of the safest alternatives for analgesia in eye surgery. Bupivacaine provides good sensory and motoric block needed in vitrectomy. However, its weakness is cardiotoxicity. Ropivacaine is a long-acting amide in local anesthetic agents which firstly produced as a pure enantiomer. Ropivacaine has a vasoconstriction property, which is useful to minimize increased intraocular pressure (IOP) after peribulbar injection. Being less lipophilic than bupivacaine, ropivacaine has less penetration to large myelinated motor fibers, which will decrease motor blockade than bupivacaine. It is also associated with decreased potential for central nervous system toxicity.
| Case Report|| |
We recently managed an 86-year-old patient who was scheduled for vitrectomy. All physical and supporting examinations revealed normal results. As we found no contraindication to do peribulbar block (i.e., infections in or surrounding the eye, high IOP, coagulopathy, allergic history to local anesthesia), we planned to manage this case by peribulbar block.
Under standard American Society of Anaesthesiologists monitoring, we prepared the patient for this procedure after applying topical pantocaine 2%. The patient was placed in supine position and then, we measured the IOP. The preprocedural IOP was 18 mmHg. We used a combination of 5 mL lidocaine 2% and 5 mL ropivacaine 0.75%, delivered by G25 needle. The peribulbar block provides blocks for ciliary, oculomotor, and abducens nerves. The needle is introduced into the extraconal space. The first injection is inferior and temporal, and the second injection is superior and nasal, between the medial third and lateral two-thirds of the orbital roof. We waited for 10 min before we re-measured the IOP using Honan ball compression and obtained that the patient's IOP was 15 mmHg. Total akinesia was observed in our patient. The surgery lasted for 90 min and went uneventful.
The pain scale on the first incision and immediately after the surgery was zero. We found no adverse effects such as ecchymosis, globe puncture, and cardiotoxicity. The patient was discharged 2 days after the surgery.
| Discussion|| |
Anesthesia with good analgesia, akinesia, and less IOP is a target for ophthalmic surgery, especially in vitrectomy operation. Less complications such as respiratory and hemodynamic compared to general anesthesia. The anesthesiologist would prefer regional anesthesia to general anesthesia, especially for old patients with multiple comorbid.
Ropivacaine is a long-acting, amide-type, local anesthetics. Ropivacaine is a pure S-enantiomer. The proton binding affinity (pKa) values will determine how long the penetration of the agent. Agents with lower pKa will provide a faster onset. The mixture of bupivacaine and lidocaine is often used based on the theoretical belief that this mixture provides a quicker onset and a longer duration of analgesia.
The lidocaine-bupivacaine mixture is currently used at our institution for the peribulbar block. The spread of local anesthetic agents which injected to adipose tissue of the orbit remains unpredictable, which there is no certainty or maybe need for more anesthetic to prevent an imperfect block. Higher concentration may facilitate diffusion of local anesthetic molecules into the peripheral nervous tissue, improving the onset of nerve blockade, lower potential for systemic toxicity of ropivacaine compared with bupivacaine enables it to be used for surgical anesthesia in concentrations up to 1%.
Perello et al. found no difference of the akinesia onset in their randomized control trial comparing plain ropivacaine with bupivacaine-lidocaine and ropivacaine-lidocaine mixtures for peribulbar blocks in cataract surgery. Nevertheless, another study reported that akinesia was achieved faster with ropivacaine compared to bupivacaine.
We also observed a decrease in IOP at 10 min after peribulbar block. Nociti found that besides provide similar analgesia and akinesia, 1% ropivacaine also decreased the IOP after its administration. The decrease could be due to the vasoconstriction effect of ropivacaine, leading to decrease in intraocular and choroid blood volume.
| Conclusion|| |
A combination of ropivacaine 0.75% and Lidocaine 2% can be used as an alternative agent in the peribulbar block in vitrectomy to provide sufficient analgesia and akinesia.
Declaration of patient consent
The authors certify that they have obtained all appropriate consent from the patient's son. In the form, the patient's son has/have given his/her/their consent for the patient's images and other clinical information to be reported in the journal. The patient's son understand that the patient's names and initials will not be published, and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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