|Year : 2017 | Volume
| Issue : 1 | Page : 224-229
Comparative study between a combination of lidocaine and levobupivacaine and that of lidocaine, levobupivacaine, and dexmedetomidine during peribulbar anesthesia for phacoemulsifi cation cataract surgery
Joseph Makram Botros, Maged Labib boulos
Lecturer of Anesthesiology, Intensive Care, Faculty of Medicine, Fayoum University, Egypt
|Date of Web Publication||3-Aug-2018|
Joseph Makram Botros
105 Toman Bai Street, Zeitoun, Cairo 11321
Source of Support: None, Conflict of Interest: None
Background and objective Eye surgeries are very common nowadays. Most surgeries, including cataract surgeries, can be safely performed in an outpatient setting using local anesthesia. Levobupivacaine, a levorotatory isomer of the racemic mixture of bupivacaine, has been used at regional blocks, including local eye blockades. Dexmedetomidine, a potent, highly selective and specific α2-adrenoreceptor agonist, with both sedative and analgesic effects and no respiratory depression, is used as an adjuvant to local eye anesthesia to prolong the analgesic duration of the local anesthetic used. We expected that the addition of dexmedetomidine to levobupivacaine would increase both sensory and motor block durations compared with levobupivacaine alone.
Patients and methods In our study, a total of 80 patients of both sexes, aged 50–70 years, belonging to the American Society of Anesthesiologists (ASA) grade I and II, and scheduled for phacoemulsification cataract surgery were randomly allocated into one of two study groups: the levobupivacaine group (group L), in which 40 patients received 3 ml of 2% lidocaine with 10 IU/ml of hyaluronidase + 3 ml of 0.5% levobupivacaine+1 ml of normal saline; and the levobupivacaine dexmedetomidine group (group LD), in which 40 patients received 3 ml of 2% lidocaine with 10 IU/ml of hyaluronidase+3 ml of 0.5% levobupivacaine+1 ml of dexmedetomidine (100 μg).
Results There was no significant difference between the two groups regarding the onset times of lid akinesia, globe anesthesia, and globe akinesia (P > 0.05). The duration of globe anesthesia, lid akinesia, and globe akinesia in the dexmedetomidine group was significantly longer than in the levobupivacaine group (P < 0.001). In group LD, the first analgesic requirement was significantly delayed and the total analgesic consumption in the first 24 h was significantly lower compared with group L (P < 0.0001 for both).
Conclusion The addition of 100 μg dexmedetomidine as an adjuvant to 2% lidocaine with 10 IU/ml of hyaluronidase and 0.5% levobupivacaine in peribulbar anesthesia for cataract surgery significantly increases the duration of peribulbar block and improves the analgesic duration, without significant side effects, and significantly decreases the intraocular pressure.
Keywords: cataract surgery, dexmedetomidine, local anesthetics, peribulbar block
|How to cite this article:|
Botros JM, boulos ML. Comparative study between a combination of lidocaine and levobupivacaine and that of lidocaine, levobupivacaine, and dexmedetomidine during peribulbar anesthesia for phacoemulsifi cation cataract surgery. Ain-Shams J Anaesthesiol 2017;10:224-9
|How to cite this URL:|
Botros JM, boulos ML. Comparative study between a combination of lidocaine and levobupivacaine and that of lidocaine, levobupivacaine, and dexmedetomidine during peribulbar anesthesia for phacoemulsifi cation cataract surgery. Ain-Shams J Anaesthesiol [serial online] 2017 [cited 2020 Aug 13];10:224-9. Available from: http://www.asja.eg.net/text.asp?2017/10/1/224/238462
| Introduction|| |
Life expectancy has increased over the last few decades due to advanced medical diagnostic and therapeutic techniques. The trend is shifting toward a better quality of life by taking advantage of these medical advancements. As a result, an increasing number of patients are coming to the hospital for various therapeutic and diagnostic procedures .
Cataract is a major cause of blindness worldwide . The increasing popularity of phacoemulsification day- care cataract surgery has started drawing a huge proportion of the population to the ophthalmological outpatient departments. The majority of these patients belong to the geriatric age group and invariably suffer from various systemic diseases including hypertension, cardiac disease, diabetes, etc., and the only effective treatment is surgery. Surgery in this population is always challenging and is associated with various risks, whether it is performed under general anesthesia or regional anesthesia .
Peribulbar anesthesia remains a popular choice for patients undergoing cataract surgery . Several studies have demonstrated that peribulbar anesthesia provides optimal conditions for cataract surgery . Furthermore, the injection of local anesthetic external to the muscle cone may decrease the likelihood of optic nerve and globe perforation .
Levobupivacaine, a levorotatory isomer of the racemic mixture of bupivacaine, was introduced into clinical practice in the last decade . It has been used at all regional blockades, including local eye blockades . The doses used are very similar to those of bupivacaine, with lower arrhythmogenic potential, lesser depressant effect on the cardiac muscle, and less depressing action on the central nervous system . Dexmedetomidine is a potent, highly selective, and specific α2-adrenoreceptor agonist and has both sedative and analgesic effects with no respiratory depression. In addition, it possesses sympatholytic and antinociceptive effects, which allow hemodynamic stability during surgical stimulation ,. Dexmedetomidine has been used as an additive to local anesthetics in peripheral nerve block, brachial plexus block , and subarachnoid anesthesia to shorten the onset and prolong the duration of analgesia. Compared with clonidine, dexmedetomidine is about eight times more specific regarding α2: α1 selectively with ratio of 1600: 1 .
The aim of this study was to compare the anesthetic effects of the addition of dexmedetomidine to the combination of lidocaine 2% with 10 IU/ml of hyaluronidase and levobupivacaine 0.5% versus the anesthetic effect of lidocaine 2% with 10 IU/ml of hyaluronidase and levobupivacaine 0.5% during peribulbar anesthesia for phacoemulsification cataract surgery.
| Patients and methods|| |
After obtaining approval of the hospital's ethical committee, an informed consent from all patients, this prospective, double-blind comparative study was conducted at Fayoum University Hospital on 80 patients of both sexes undergoing phacoemulsification cataract surgery in the period between January 2013 and June 2013; patients’ ages ranged between 50 and 70 years. All patients included in the study belonged to ASA physical class I and II.
The exclusion criteria included patients with advanced cardiac disease, patients with active ocular infection and high myopia, single-eyed patients, patients with coagulopathy or on anticoagulant therapy, patients on antiepileptic medication, patients receiving antiglaucomatous drugs, and patients known to be allergic to bupivacaine and lidocaine.
Using a computer-generated list, the patients were randomly and evenly assigned into two equal groups:
- Levobupivacaine group (group L), in which 40 patients received 3 ml of 2% lidocaine with 10 IU/ml of hyaluronidase+3 ml of 0.5% levobupivacaine+1 ml of normal saline.
- Levobupivacaine dexmedetomidine group (group LD), in which 40 patients received 3 ml of 2% lidocaine with 10 IU/ml of hyaluronidase+3 ml 0.5% levobupivacaine+1 ml of dexmedetomidine (100 μg).
All healthcare personnel providing direct patient care were blinded to the study drugs injected. All medications were prepared by anesthesiologists not participating in the study.
On arrival in the operating room, all patients were monitored by five-lead ECG (leads II and V simultaneously) for pulse oximetry and noninvasive arterial blood pressure.
For all patients, a 22-G size peripheral intravenous cannula was inserted in the preparation room and a nasal cannula was placed to administer oxygen at a flow rate of 3–4 l/min. The procedure was fully explained to the patients (both anesthetic block and surgery-related issues, e.g., lying still), and their stay during in the hospital was made comfortable so as to ensure patient cooperation.
Patients received 2 mg of midazolam with 20 ug of fentanyl sulfate intravenously before surgery for sedation and analgesia. Patients were then taken into the operating room where they received supplementary oxygen through a nasal cannula, and were monitored.
Baseline intraocular pressure (IOP) was measured using a Schiotz tonometer after applying topical anesthesia with 0.5% tetracaine hydrochloride drops.
Block was carried out by a single inferotemporal injection of a local anesthetic solution. Before the start of the operation, an intravenous infusion was initiated to administer Ringer's lactate solution, and afterwards patient assurance and monitoring continued throughout the procedure.
Intermittent ocular compression was performed for 5–10 min using a Honan balloon set at 30 mmHg (millimeter mercury). Ocular movement score was also evaluated using a three-point scoring system in all the four quadrants (grade 0 = akinesia – i.e., ocular movement < 1 mm; grade 1 = moderately reduced ocular movements – i.e., >1 mm and < 3 mm; and normal ocular movements – i.e., >3 mm).
After the administration of peribulbar blocks, heart rate (HR), mean arterial pressure, and oxygen saturation were observed and recorded during the surgical period.
Hypotension, defined as a decrease in systolic blood pressure by more than 20% of the baseline, was treated with 5 mg of ephedrine intravenously. Bradycardia, defined as HR less than 50 beats/min, was treated with 0.4 mg atropine intravenously.
Adverse events like nausea, vomiting, pruritus, and shivering were recorded and treated.
The duration of sensory and motor block were assessed by onset of pain (time elapsed from time of injection to appearance of pain recorded) and recovery of eye ball movements (time from injection till normal ocular movements, i.e., greater than 3 mm in all directions).
The time to first request for analgesic (time from injection till first patient request for analgesic) and the total analgesic requirement of intramuscular ketorolac in the first 24 h were recorded. All the patients were discharged on the next morning of surgery.
IOP was measured at three times intervals after 1, 5 and 10 min from completion of the block.
Data were collected by independent observers who were blinded for the purpose of the study. The endpoint (primary outcome) of this study was increase in both sensory and motor duration of the peribulbar blockade with the addition of dexmedetomidine to the local anesthetic (levobupivacaine).
Collected data were computerized and analyzed using the Statistical Package for Social Science (SPSS) version 16 (Nie, Bent & Hull, 1970, current versions (2015) IBM SPSS Statistics, USA). Descriptive statistics were used to describe variables: percent and number for qualitative variables; and mean, SD, and range for quantitative variables.
Comparison between the groups was done using the χ2-test for qualitative variables, and Fisher's exact test and independent Student t-test for quantitative variables. Paired comparison within groups was carried out using the paired t-test. P values less than 0.05 were considered statistically significant.
A clinically significant effect of 15% or more was important for the sample size estimation of this trial. Assuming mean of duration of globe anesthesia in the control group and the intervention group of 200 and 215, respectively, and a pooled SD of 20 with a two- sided significance of 0.05 and a power of 0.90, a total of 80 patients were required.
| Results|| |
For all the patients who underwent cataract surgery, a proper record was maintained regarding the demographic characteristics, peribulbar block characteristics, IOP, hemodynamic parameters, time of first analgesic rescue, and side effects.
Demographic profi le and operative data
The mean age in group L (61.8 ± 6.1 years) was comparable to the mean age in group LD (61.08 ± 5.6 years) (P > 0.05). Duration of surgery in both the groups was comparable and insignificant on statistical analysis. To summarize, all the demographic characteristics like age, sex, weight, ASA grade, side of the eye operated, axial length, and duration of surgery were comparable in the two groups, and were found to be statistically insignificant (P > 0.05) ([Table 1]).
|Table 1 Demographic profi le and operative data of the patients who underwent phacoemulsifi cation cataract surgery|
Click here to view
Onset and duration of block
There was no significant difference between the two groups regarding the onset times of lid akinesia, globe anesthesia, and globe akinesia (P>0.05). The duration of globe anesthesia, lid akinesia, and globe akinesia in the dexmedetomidine group was statistically significantly longer when compared with the levobupivacaine group (P < 0.001) ([Table 2]).
IOP increased transiently during the first 1–2 min after the administration of the block in both groups and the comparative change was not found to be significant. IOP came to the baseline value over the next 1 min. Thereafter, the IOP started decreasing in both groups, but the decrease was highly significant in group LD (P < 0.01) after 5 and 10 min ([Table 3]).
|Table 3 Intraocular readings in the groups L and LD at different time intervals|
Click here to view
After the administration of peribulbar block, patients in both groups had a transient increase in HR, which came to baseline within the next 1 min. The HR showed minimal variation in both groups during the entire surgical period, without significant variation between the two groups ([Figure 1]). Mean arterial pressure also projected a similar picture as mean HR ([Figure 2]).
|Figure 1 Comparison between the two groups as regards heart rate changes. L, levobupivacaine group; LD, levobupivacaine/dexmedetomidine group.|
Click here to view
|Figure 2 Comparison between the two groups as regards changes in the reading of mean arterial pressure (MAP). L, levobupivacaine group; LD, levobupivacaine/dexmedetomidine group.|
Click here to view
A total of 30 patients (75%) in group L required postoperative pain medication during the first 24 h compared with 20 patients (50%) in group LD, and this was statistically significant (P = 0.036). The time of first request to analgesia was significantly longer in patients of group LD (321.54 ± 76.71 min) compared with those in group L (181.3 ± 87.2 min) (P < 0.0001). The intramuscular ketorolac consumption was less in group LD (39 ± 17.137 mg) compared with the patients of group L (46 ± 21.909 mg), but it was statistically insignificant (P = 0.0.235) ([Table 4]).
The incidence of various side effects in both groups was observed in intraoperative and postoperative periods. The incidence of dry mouth was higher in group LD but with no significant difference (P > 0.05). We did not observe respiratory depression or vomiting in any patient from both groups. The incidence of other side effects like nausea, headache, hypotension, bradycardia, sedation, and shivering was comparable in both groups. The incidence of sedation in group LD (15 patients 37.5%) was significantly higher than in L group (seven patients 17.5%) (P = 0.045). In addition, the incidence of bradycardia was significantly higher in group LD (eight patients 20%) compared with group L (two patients 5%, P = 0.042) ([Table 5]).
| Discussion|| |
Regional anesthesia has gained massive popularity for daycare cataract surgery . Peribulbar block became more widely used than retrobulbar block because it provides the same anesthetic effect but with lower complications .
The results of our study showed that addition of 100 μg dexmedetomidine to 2% lidocaine with 10 IU/ml of hyaluronase and 0.5% levobupivacaine significantly prolongs the duration of globe anesthesia, lid akinesia, and globe akinesia (P < 0.001). However, no significant changes in the onset times of globe anesthesia, lid akinesia, and globe akinesia (P > 0.05) were detected, which could be attributed to the fast action of lidocaine masking the effect of dexmedetomidine ([Table 2]).
El-Ozairy and Tharwat (2014) , in their study comparing the effect of adding two different doses of dexmedetomidine (25 and 50 μg) to levobupivacaine/ hyaluronidase mixture on the peribulbar block in vitreoretinal surgery, found that the onset of corneal anesthesia in group D25 was shorter than that in the control group, and this was found to be statistically insignificant, which is in agreement with our results. However, the onset of corneal anesthesia was significantly shorter in group D50 than in group C (P = 0.018) in the same study. Moreover, they found that the onset of globe akinesia was insignificantly shorter in group D25 than in group C, which is also in agreement with our results, but it was significantly shorter in group D50 (P = 0.022) .
Furthermore, in a similar study conducted by Channabasappa et al. 17 in 2013 on 90 patients undergoing elective cataract surgery under peribulbar anesthesia, addition of two different doses of dexmedetomidine (25 and 50 μg) to a mixture of 2% lidocaine (3 ml) and 0.5% bupivacaine (3 ml) shortened the onset and prolonged the duration of the block and postoperative analgesia, respectively.
Similar observations were reported by Abdel and Ahmed (2014) , who compared the effect of adding dexmedetomidine 1 μg/kg to a local anesthetic mixture of 2% lidocaine and 0.5% bupivacaine with 10 IU/ml of hyaluronidase to the control group in retrobulbar anesthesia for retinal detachment surgery, and by Esmaoglu et al.  in 2010, who evaluated the effect of adding 100 μg dexmedetomidine to levobupivacaine for axillary brachial plexus blockade.
Similarly, El-Ozairy and Tharwat  found that the duration of corneal anesthesia was significantly higher in group D50 (390.40 ± 10.31 min) compared with groups D25 and C (164.41 ± 13.80 and 154.33 ± 17.34 min, respectively) (P < 0.001). The duration of globe akinesia was significantly higher in groups D25 and D50 compared with group C (197.30 ± 25.95, 283.10 ± 26.40, and 154.33 ± 17.34 min, respectively; P < 0.001).
In agreement with our results, Obayah et al.  reported that the addition of dexmedetomidine to bupivacaine for greater palatine nerve block prolongs postoperative analgesia after cleft palate repair by about 50%.
In the present study, we observed a transient increase in the IOP in the first 1–2 min in both groups, which could have been possibly due to the increase in intraorbital fluid volume with local anesthetic injection causing increased orbital pressure. The measurement of IOP was less in the dexmedetomidine (LD) group but the IOP variation was clinically significant (P < 0.05) after 5 min, and highly significant (P < 0.001) after 10 min ([Table 3]). Similar observations as regards IOP were reported by El-Ozairy and Tharwat . IOP was found to be significantly lower in groups D25 and D50 compared with the control group at 1, 5, and 10 min after injection, with a P value of less than 0.001.
In the present study, time to first rescue analgesia was significantly higher in group LD compared with group L (P < 0.0001). The number of patients requiring analgesia in group L [30 patients (75%)] was significantly higher than in group LD [20 patients (50%)] (P = 0.036). The intramuscular ketorolac consumption was less in group LD (39 ± 17.137 mg) compared with patients of group L (46 ± 21.909 mg), but it was statistically insignificant (P = 0.235). This may be explained by the small sample size and the need to increase the number of cases to study accurately the difference in consumption.
Similar results were reported by El-Ozairy and Tharwat  who found that time to first rescue analgesia was significantly higher in groups D25 and D50 compared with the control group (P < 0.001). The number of patients not requiring analgesia in groups D25 and D50 was higher than in the control group, although statistically insignificant [13 (65%), 16 (84.2%) compared with 11 (57.9%), P = 0.464].
As regards the side effects, the incidence of sedation and bradycardia was significantly higher in group LD compared with group L (P = 0.045 and 0.042, respectively); otherwise, the incidence of nausea and vomiting, hypotension, shivering, and dry mouth was comparable in both groups (P > 0.05).
The addition of 100 μg of dexmedetomidine as an adjuvant to 2% lidocaine with 10 IU/ml hyaluronidase and 0.5% levobupivacaine in peribulbar anesthesia for cataract surgery significantly increases the duration of peribulbar block, decreases the IOP, and improves the analgesic duration without significant side effects. However, clinical trials with a larger number of patients are required to make accurate conclusions.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Rosenthal RA, Kavic SM. Assessment and management of the geriatric patient. Crit Care Med 2004; 32(Suppl): 92–105.
Alhassan MB, Kyari F, Ejere HO. Peribulbar versus retrobulbar anesthesia for cataract surgery. Cochrane Database Syst Rev 2008; 16:CD 004083.
Bajwa SJ, Singh K, Bajwa SK, Singh A, et al.
Anesthesia considerations in a ‘very old’ geriatric patient for major orthopedic surgery. Anesth Essays Res 2010; 4:1 25–126.
Bedi A, Carabine U. Peribulbar anaesthesia: a double-blind comparison of three local anaesthetic solutions. Anaesthesia 1999; 54:67–71.
Kumar CM, Dowd TC. Complications of ophthalmic regional blocks: their treatment and prevention. Ophthalmologica 2006; 220:73–82.
Whitsett JC, Balyeat HD, McClure B. Comparison of one-injection-site peribulbar anesthesia and retrobulbar anesthesia. J Cataract Refract Surg 1990; 16:2 43–245.
Foster RH, Markham A. Levobupivacaine: a review of its pharmacology and use as a local anaesthetic. Drugs 2000; 59:5 51–579.
McClellan KJ, Spencer CM. Levobupivacaine. Drugs 1998; 56:3 55–364.
Bardsley H, Gristwood R, Baker H, Watson N, Nimmo W. A comparison of the cardiovascular effects of levobupivacaine and rac-bupivacaine following intravenous administration to healthy volunteers. Br J Clin Pharmacol 1998; 46:2 45–249.
Rizzo L, Marini M, Rosati C, Calamai I, Nesi M, Salvini R, et al.
Peribulbar anesthesia: a percuteneous single injection technique with a small volume of anesthetic. Anesth Analg 2005; 100:94–96.
Frow MW, Miranda-Caraballo JI, Akhtar TM, Hugkulstone CE. Single injection peribulbar anaesthesia. Total upper eyelid drop as an end-point marker. Anaesthesia 2000; 55:7 50–756.
Gandhi RR, Shah AA, Patel I. Use of dexmedetomidine along with bupivacaine for brachial plexus block. Natl J Med Res 2012; 2:67–69.
Kamibayashi T, Maze M. Clinical uses of alpha2-adrenergic agonists. Anesthesiology 2000; 93:134 5–1349.
Khan B, Bajwa SJ, Vohra R, Singh S, Kaur R, VartikaAsha Comparative evaluation of ropivacaine and lignocaine with ropivacaine, lignocaine and clonidine combination during peribulbar anaesthesia for phacoemulsification cataract surgery. Indian J Anaesth 2012; 56: 21–26.
Fahmy NG, Fahmy AM, Kamal KY. Clonidine versus fentanyl as adjuvants to bupivacaine in peribulbar anesthesia. Ain Sham J Anaesthesiol 2011; 4:41–47.
HS El-Ozairy, AI Tharwat. Comparative study of the effect of adding two different doses of dexmedetomidine to levobupivacaine/hyaluronidase mixture on the peribulbar block in vitreoretinal surgery. Ain Shams J Anesth 2014; 7:3 93–399.
Channabasappa SM, Shetty VR, Dharmappa SK, Sarma J. Effi cacy and safety of dexmedetomidine as an additive to local anesthetics in peribulbar block for cataract surgery. Anesth Essays Res 2013; 7:39–43.
D Abdel, G Ahmed. Addition of dexomedetomidine to local anaesthesia for retrobulbar block: does it improve the quality of anesthesia? Int J Anesth Res 2014; 2:35–39.
Esmaoglu A, Yegenoglu F, Akin A, Turk CY. Dexmedetomidine added to levobupivacaine prolongs axillary brachial plexus block. Anesth Analg 2010; 111:154 8–1551.
Obayah GM, Refaie A, Aboushanab O, Ibraheem N, Abdelazees M. Addition of dexmedetomidine to bupivacaine for greater palatine nerve block prolongs postoperative analgesia after cleft palate repair. Eur J Anaesthesiol 2010; 27:28 0–284.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]