Hemodynamic stability in an optimized propofol-remifentanil based anesthesia for ophthalmic surgery.

Background and Goal of the Study: A deep level of anesthesia is often required in ophthalmic surgery to obtain optimal surgical conditions, which may induce significant cardiovascular impairment and compromise tissue oxygenation. We investigated the hemodynamic stability and tissue oxygenation in a balanced general anesthesia with remifentanil, low-dose propofol, norepinephrine and goal-directed fluid administration in patients undergoing ophthalmic surgery. Material and Methods: 40 consecutive patients were included after informed consent was obtained. Anesthesia was induced with 1-3 mg kg-1 propofol, 1 µg kg-1 remifentanil, 0.1 mg kg-1 cisatracurium and an additional bolus of norepinephrine 10 µg, if required. Anesthesia was maintained with 4 mg kg-1 min-1 propofol, 0.25 µg kg-1 min-1 remifentanil and 0.05 µg kg-1 min-1 norepinephrine if required and further titrated to a MAP above 80% of baseline. Propofol or remifentanil infusion was increased upon the discretion of the anesthetist and targeted to a BIS value between 40 - 60. Voluven® 500ml was administered if the plethysmographic wave variation was > 10%. Tissue oxygen saturation (StO2) was measured by near-infrared spectroscopy using the Inspectra device (Model 650, Hutchinson Technology, USA) at the left thenar eminescence. Hemodynamics (cardiac index (CI), mean arterial pressure (MAP) and heart rate (HR)) were measured non-invasively (Nexfin, BMEye, Amsterdam). Results and Discussion: Mean (SD) StO2 increased from 83 (6) % before induction to 86 (4) % 20 minutes after induction of anesthesia (p< 0.05) and remained stable throughout the procedure. Cardiac index dropped from 3.0 (0.7) to 2.1 (0.4) L min-1 after 20 minutes (p< 0.05). Furthermore MAP decreased from 109 (16) to 83 (14) mm Hg and HR from 73 (12) to 54 (8) bpm (both p< 0.05). 14/40 patients received a 500 ml Voluven bolus. The median (range) norepinephrine administration rate was 0.05 (0.0 - 0.10) µg kg-1 min-1. The overall median (IQR) BIS value from induction of anesthesia to the end of the procedure was stable in all patients and was 44 (40 - 51), while 3/40 patients required additional propofol or remifentanil. Conclusion: This balanced protocol based on remifentanil, low-dose propofol, norepinephrine and goal-directed fluid therapy preserves StO2 while other hemodynamic variables are within a clinically acceptable range, suggesting this protocol to be feasible for use in anesthesia for ophthalmic surgery

Increase in treatment of retinopathy of prematurity in the Netherlands from 2010 to 2017

Purpose: Compare patients treated for Retinopathy of Prematurity (ROP) in two consecutive periods. Methods: Retrospective inventory of anonymized neonatal and ophthalmological data of all patients treated for ROP from 2010 to 2017 in the Netherlands, subdivided in period (P)1: 1-1-2010 to 31-3-2013 and P2: 1-4-2013 to 31-12-2016. Treatment characteristics, adherence to early treatment for ROP (ETROP) criteria, outcome of treatment and changes in neonatal parameters and policy of care were compared. Results: Overall 196 infants were included, 57 infants (113 eyes) in P1 and 139 (275 eyes) in P2, indicating a 2.1-fold increase in ROP treatment. No differences were found in mean gestational age (GA) (25.9 ± 1.7 versus 26.0 ± 1.7 weeks, p = 0.711), mean birth weight (791 ± 311 versus 764 ± 204 grams, p = 0.967) and other neonatal risk factors for ROP. In P2, the number of premature infants born <25 weeks increased by factor 1.23 and higher oxygen saturation levels were aimed at in most centres. At treatment decision, 59.6% (P1) versus 83.5% (P2) (p = 0.263) infants were classified as Type 1 ROP (ETROP classification). Infants were treated with laser photocoagulation (98 versus 96%) and intravitreal bevacizumab (2 versus 4%). Retreatment was necessary in 10 versus 21 (p = 0.160). Retinal detachment developed in 6 versus 13 infants (p = 0.791) of which 2 versus 6 bilateral (p = 0.599). Conclusion: In period 2, the number of infants treated according to the ETROP criteria (Type 1) increased, the number of ROP treatments, retinal detachments and retreatments doubled and the absolute number of retinal detachments increased. Neonatal data did not provide a decisive explanation, although changes in neonatal policy were reported

Strategy for the management of complex retinal detachments: the European vitreo-retinal society retinal detachment study report 2

OBJECTIVE: To study the outcome of the treatment of complex rhegmatogenous retinal detachments (RRDs). DESIGN: Nonrandomized, multicenter, retrospective study. PARTICIPANTS: One hundred seventy-six surgeons from 48 countries spanning 5 continents reported primary procedures for 7678 RRDs. METHODS: Reported data included clinical manifestations, the method of repair, and the outcome. MAIN OUTCOME MEASURES: Failure of retinal detachment repair (level 1 failure rate), remaining silicone oil at the study's conclusion (level 2 failure rate), and need for additional procedures to repair the detachments (level 3 failure rate). RESULTS: The main categories of complex retinal detachments evaluated in this investigation were: (1) grade B proliferative vitreoretinopathy (PVR; n = 917), (2) grade C-1 PVR (n = 637), (3) choroidal detachment or significant hypotony (n = 578), (4) large or giant retinal tears (n = 1167), and (5) macular holes (n = 153). In grade B PVR, the level 1 failure rate was higher when treated with a scleral buckle alone versus vitrectomy (P = 0.0017). In grade C-1 PVR, there was no statistically significant difference in the level 1 failure rate between those treated with vitrectomy, with or without scleral buckle, and those treated with scleral buckle alone (P = 0.7). Vitrectomy with a supplemental buckle had an increased failure rate compared with those who did not receive a buckle (P = 0.007). There was no statistically significant difference in level 1 failure rate between tamponade with gas versus silicone oil in patients with grade B or C-1 PVR. Cases with choroidal detachment or hypotony treated with vitrectomy had a significantly lower failure rate versus treatment with scleral buckle alone (P = 0.0015). Large or giant retinal tears treated with vitrectomy also had a significantly lower failure rate versus treatment with scleral buckle (P = 7×10(-8)). CONCLUSIONS: In patients with retinal detachment, when choroidal detachment, hypotony, a large tear, or a giant tear is present, vitrectomy is the procedure of choice. In retinal detachments with PVR, tamponade with either gas or silicone oil can be considered. If a vitrectomy is to be performed, these data suggest that a supplemental buckle may not be helpful. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article