American Journal of Medicine and Medical Sciences 2022, 12(1): 71-74
DOI: 10.5923/j.ajmms.20221201.14
Application of Different Options of Combined Inhalation
Anesthesia for Intraocular Interventions in Children
Satvaldiyeva E., Yusupov A., Mamаtkulov I., Fayziyev O., Mamаtkulov I.
*
Tashkent Pediatric Medical Institute, Tashkent, Uzbekistan
Abstract
Prevention and elimination of increased intraocular pressure is one of the most important tasks of an
anesthesiologist during ophthalmic operations, therefore, the search for optimal anesthesia schemes is an urgent problem of
modern anesthesiology. The aim of the work was to evaluate the effectiveness of combined methods of anesthesia in
intraocular surgery in children by analyzing hemodynamic parameters. We examined 46 children who needed
ophthalmological operations. The following anesthesia schemes were used: sevoflurane + fentanyl (group 1), propofol +
fentanyl (group 2). Anesthesia effectiveness was assessed on the basis of clinical data with monitoring of the main
hemodynamic and respiratory parameters. The results showed that the anesthesia regimens used were characterized by a
smooth clinical course, while maintaining the stability of the main hemodynamic parameters.
Keywords
Anesthesia, Children, Hemodynamics, Intraocular pressure, Ophthalmic operations
1. Relevance
Ophthalmic operations, like any surgical interventions,
require anesthesia and elimination of discomfort for the
patient associated with the necessary manipulations.
Anesthesia allows for both short-term outpatient and
complex long-term surgical procedures, the purpose of
which is restoration of vision, reconstruction of the orbit,
and elimination of cosmetic defects. The specificity of
intraocular operations is associated with the problems
of local hemostasis, blood circulation, regulation of
ophthalmotonus, which requires special training from the
anesthesiologist [1,2,3,4]. In pediatric anesthetic practice,
the problem of anesthesia remains associated with the
development of possible complications, the development of
an oculocardial reflex (slowing heart rate up to cardiac
arrest), oculogastric (hiccups, vomiting) or oculorespiratory
(breath holding, laryngospasm) [5,8,12]. A wide selection
of drugs for anesthesia (fentanyl and inhalation anesthetics)
in the first positions, requires their adequate combinations,
maintaining the stability of the state of central
hemodynamics, taking into account their both positive and
negative characteristics, as well as noting the ability of drugs
to reduce intraocular pressure, which is important in
pediatric ophthalmosurgery [6,9,10]. In this regard, the
choice of various options for combined anesthesia that
adequately provides anesthesia and does not have negative
* Corresponding author:
jakhongir2025@gmail.com (Mamаtkulov I.)
Received: Dec. 10, 2021; Accepted: Jan. 14, 2022; Published: Jan. 27, 2022
Published online at http://journal.sapub.org/ajmms
effects on the div of children with intraocular interventions
remains relevant [7,11].
Purpose of references:
Improving the anesthetic
protection of children using inhalation anesthesia with
sevoflurane for intraocular interventions.
2. Material and Methods
To provide anesthetic protection in 46 sick children during
ophthalmic surgery, the following combinations were used:
fentanyl with sevoflurane - group 1 - 24 patients (52.2%),
fentanyl with propofol - group 2 - 22 patients (47.8%).
Children aged 3-6 years accounted for 34.8% of the total
number of patients, 7-10 years old - 34.8% and older (11-14
years old) - 30.4%.
Anesthesia was performed during operations with opening
the anterior chamber of the eye (congenital glaucoma);
congenital and traumatic cataracts with artificial lens
implantation; cataract extraction; the duration of anesthesia
in 59.4% of patients was up to 1 hour, in 40.6% - up to 2
hours.
Patients of group 1 after premedication started inhalation
of sevoflurane up to 3 vol%. Fentanyl was administered
intravenously at a dose of 0.003 μg / kg.
During induction, patients of the second group were
started with intravenous administration of propofol at a dose
of 3 mg / kg, and a solution of fentanyl at a dose of 0.004 μg
/ kg was administered. Patients of both groups underwent
tracheal intubation against the background of the
administration of arduan at a dose of 0.006 mg / kg. The
mechanical ventilation was carried out by the device Drager
- "Fabius Plus" (Germany) along a semi-closed circuit.
72
Satvaldiyeva E.
et al.
: Application of Different Options of Combined
Inhalation Anesthesia for Intraocular Interventions in Children
Muscle relaxation was supported by the introduction of 1/3
of the main dose of Arduan. Anesthesia was maintained
by repeated administration of fentanyl at a dose of 50% or
25% of the initial dose. In the first group, anesthesia was
maintained by inhalation of sevoflurane at a dose of 1.0-1.8
vol% and repeated fractional administration of fentanyl
(50% or 25% of the initial dose), in the second group,
anesthesia was maintained by intravenous administration of
propofol through a lineomat at a dose of 7.5 mg / kg / hour
and repeated fractional administration of fentanyl (50% or
25% of the initial dose). Infusion therapy was carried out at
a rate of 5-7 ml / kg / hour. After the end of the operation,
tracheal extubation was performed against the background of
adequate spontaneous breathing. The average awakening
time for patients in the first group was 11.8 ± 0.8 minutes, for
patients in the second group it was 15.5 ± 2.2 minutes.
The study of hemodynamic parameters was carried out
on a SonoScape echocardiograph (Italy) with a 3.5 MHz
transducer according to the standard protocol. To assess the
functional state of the cardiovascular system during
anesthesia, the following indicators were studied: stroke
index (SI), cardiac index (SI) and total peripheral vascular
resistance (OPSS). Stroke index (ml / m2) = Stroke volume
of the heart / Body surface area. Cardiac Index (L / min / m2)
= Circulatory Minute / Body Surface Area. Total peripheral
vascular resistance = Systolic blood pressure / Heart index.
The expulsion fraction indicator - (PI) of the left ventricle
(LV) is an integral measure of myocardial contractility,
which characterizes the value of the volume of ejected LV
blood in relation to its diastolic volume.
The measurement of intraocular pressure was carried out
according to A.N. Maklakov before and after surgery [6].
Normal IOP is 16-23 mm Hg. Art.
The results of clinical and functional studies were
processed by the method of variation statistics Student's
t-test.
3. Research Results and Their
Discussion
The results of the study of hemodynamic parameters in
children of group I (fentanyl + sevoflurane) are presented in
table 1.
Compared with the initial data, against the background of
premedication, there was an increase in heart rate by 17.5%
and a decrease in specific peripheral resistance (UPS) by
20.7%. It should be noted that the patients of the first group
reacted more significantly to the induction of anesthesia and
anesthesia. Even before the induction of anesthesia, they had
tachycardia and a moderate rise in blood pressure, which was
associated with the psychoemotional stress of the patients.
Other indicators changed slightly. After the introduction of
fentanyl, hemodynamic parameters such as SI, SI, PI and
heart rate decreased in comparison with those of the
premedication period, respectively, by 14.2% (P <0.05),
3.4%, 8.6%, 4.2% and 2.3, excluding OOPS. The revealed
significant differences in the response of systemic
hemodynamics are associated with the characteristics of the
pharmacological action of both fentanyl and sevoflurane. 10
minutes after intubation, there was a significant increase in
SI by 20.4%, SI by 21.7%, at the same time, there was a
decrease in UPS by 13.86% (p <0.05).
There is a tendency towards a decrease in the expulsion
fraction (EF).
Under the influence of drugs for premedication in patients
of the second group (Table 2), the following hemodynamic
changes were observed: an increase in heart rate by 6.5%
(p <0.05), SI by 2.5%, SI by 2.3%, UPS by 2.74% and PI
by 1.11% (P> 0.05) associated with emotional discomfort
before surgery and exposure to premedication drugs.
At the stage of induction of anesthesia, slight changes in
hemodynamic parameters were observed, for example: UI,
HR, SI by 1.44%, 2.42%, 1.48%, respectively. At the same
time, UPS and PI increased insignificantly - by 0.1% and
0.13%, respectively, which turned out to be statistically
insignificant (P> 0.05). A significant decrease in comparison
with the premedication stage was revealed in relation to
the heart rate, which decreased by 12.01% (p <0.05).
Considering the hypotensive effect of fentanyl, sevoflurane
and propofol, infusion therapy was started without waiting
for a critical drop in blood pressure, regardless of its initial
value, at a minimum rate. This approach made it possible to
prevent, and in some cases completely neutralize the critical
drop in blood pressure at all stages of anesthetic treatment.
Table 1.
Hemodynamic parameters during combined anesthesia with fentanyl and sevoflurane (M ± m)
Indicators
Research stages (n = 10)
Exodus
Premewildtion
Induction into
anesthesia
Traumatic stage
End of the
operations
UI, ml / m
2
42,14±0,99
39,34±1,69
33,75±0,96***
39,22±2,11
41,33±1,04
Heart rate, min
–1
113,0±6,64
132,8±5,9
129,1±3,15
124,9±6,15
117,7±5,89
SI, l / min x m
2
4,82±0,41
4,9±0,28
4,48±0,29
4,66±0,26
4,83±0,27
UPS, conv. units
18,18±1,57
14,41±1,07
17,0±0,73
17,63±1,44
15,57±1,48
FI,%
62,73±1,66
65,09±2,89
62,36±2,7
63,19±3,16
65,57±2,24
*- reliability of differences in indicators compared with the baseline value (p <0.05)
**- reliability of differences in indicators compared with the previous stage of the study (p <0.05).
American Journal of Medicine and Medical Sciences 2022, 12(1): 71-74
73
Table 2.
Changes in hemodynamic parameters during general anesthesia with fentanyl in combination with propofol (M ± m)
Indicators
Stages of surgery and anesthesia (n = 30)
Exodus
Premedication
Induction into
anesthesia
Traumatic the first
stage of the operation
End of
operation
UI, ml / m
2
47,26±1,61
48,44±1,59
46,58±1,3
47,14±1,41
47,38±3,27
Heart rate, min
–1
119,13±1,82
126,81±2,2*
119,06±2,25**
120,54±2,06
123,94±2,02
SI, l / min x m
2
4,73±0,16
4,84±0,16
4,66±0,13
5,61±0,23***
5,97±0,51*
UPS, conv. units
68,29±5,03
70,16±5,39
68,36±4,82
68,13±5,05
72,72±8,13
FI,%
63,76±0,57
64,47±0,72
63,84±0,48
63,51±0,55
63,73±0,47
* - reliability of differences at p <0.05 compared with the baseline value
** - reliability of differences at p <0.05 compared with the previous stage of the study
At the end of the operation, hemodynamic parameters
remained stable. The changes in the studied indicators at the
stages of the operation, ascertained by us, were unreliable,
except for the SI indicator. In relation to their initial value,
there was some change, which was expressed by an increase
in SI by 26.2% (p <0.05).
Intraocular pressure was studied. Table 3 shows the results
of measuring intraocular pressure.
Table 3.
The value of intraocular pressure depending on the option of
anesthetic aid
Type of anesthesia
Before surgery,
mm Hg Art.
After surgery,
mm Hg Art.
Fentanyl + Sevoflurane
26,8±1,67
23,2±1,37
Fentanyl + Propofol
24,2±1,21
22,4±1,39
In patients of the first group in the postoperative period,
there was a slight decrease in IOP by 13.43%, in group 2 - by
7.44% (P <0.05).
In the discussion, it should be noted that the indicators of
central hemodynamics in patients of group 1 indicated the
presence of moderate hypodynamia of blood circulation.
Sevoflurane mainly affected the tone of the peripheral
vascular bed, causing vasoplegia. At the same time, fentanyl
decreased cardiac output, increasing vascular vasoplegia.
This condition was eliminated against the background of
infusion therapy. In children of the second group, the reasons
for the decrease in the SI indicator were the presence
of rigidity of the microvasculature, limited cantractile
capabilities of the heart muscle, and a relative deficit of the
BCC. With the use of fentanyl and sevoflurane, patients
fell asleep smoothly and quickly, without signs of agitation,
the stability of hemodynamic parameters during all periods
of anesthesia and in the early post-narcotic period. The
postoperative period was uneventful - the awakening of
patients occurred without pronounced signs of excitement,
changes in hemodynamics. This made it possible to perform
early extubation of patients and transfer them to the
ophthalmology department for further treatment. With the
combination of sevoflurane with fentanyl, there was no
increase in intraocular pressure, and general anesthesia
occurred predictably quickly, proceeded stably, followed by
a quick and smooth recovery of consciousness and somatic
functions without straining and vomiting. Thus, combined
anesthesia with fentanyl and sevoflurane makes it possible to
create the most adequate conditions for surgical correction,
minimize the negative effects of its individual components,
and maximize the specific tasks of anesthesia during
ophthalmic operations in children.
4. Conclusions
1. Changes in hemodynamic parameters depending
on the method of anesthesia during intraocular
ophthalmic operations in children were insignificant
and were of a compensatory nature, which indicated
the effective anesthetic protection of the child's div
from surgical trauma.
2. Anesthesia based on inhalation anesthetics in
combination with fentanyl is accompanied by a
decrease in intraocular pressure, which creates
optimal conditions for surgical interventions in
children with increased intraocular pressure.
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