|Year : 2019 | Volume
| Issue : 1 | Page : 33-38
Comparative study between cisatracurium, atracurium as an adjuvant agent to local anesthetics on peribulbar anesthesia in adult healthy patients
Marwa M Elgohary, Abd El-Azez H El Badawy, Ahmed S Elgebaly, Wesam M. A Nassar
Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Tanta University, Tanta, Egypt
|Date of Submission||01-Mar-2017|
|Date of Acceptance||01-Sep-2017|
|Date of Web Publication||17-Sep-2019|
Marwa M Elgohary
Surgical Intensive Care, Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Tanta University, 10 Masged El Eeda St. from Reyad Ghoraba, Tanta, El-Gharbia
Background Patients with cataracts tend to be older and to have serious comorbidities and there is evidence that local anesthetic causes fewer adverse events than general anesthesia as well as reduces the recovery time of the patient. Many adjuvant drugs have been shown to improve the quality of peribulbar anesthesia.
Aim The aim was to compare the effect of using atracurium and cisatracurium as an adjuvant to local anesthetic on peribulbar anesthesia in cataract surgeries.
Patients and methods A total of 90 patients of both sexes belonging to the American Society of Anaesthesiology I and II status scheduled for cataract surgery using peribulbar anesthesia were divided into three equal groups as follows. Group I: received only bupivacaine and lidocaine, group II received bupivacaine+lidocaine+atracurium, and group III patients received bupivacaine+lidocaine+cisatracurium.
Results There was a significant increase in time to begin surgery in group I when compared with groups II and III (P=0.001). There was a statistically significant difference (P=0.001) in akinesia score at 1, 3, 5, 7, and 10 min between groups. Also, there was a statistically significant difference (P=0.001) in eyelid squeezing score at 1, 3, 5, 7, and 10 min between groups. There was an increased number of patients who required supplementary dose in group I (33.3%) than in groups II (10%) and group III (10%) (P=0.024). Rapid offset of akinesia occurred in group I than in group II and group III (P=0.001). Intraoperative pain using the visual analog scale score was statistically insignificant (P>0.05) between groups. There was no statistical difference between groups I, II, and III regarding complications and adverse effects.
Conclusion Addition of muscle relaxant (atracurium or cisatracurium) in peribulbar anesthesia provides better akinesia, rapid onset, and more prolonged time of akinesia; it also decreases the need for supplementary injection.
Keywords: akinesia, atracurium, cisatracurium, peribulbar
|How to cite this article:|
Elgohary MM, El Badawy AAH, Elgebaly AS, Nassar WA. Comparative study between cisatracurium, atracurium as an adjuvant agent to local anesthetics on peribulbar anesthesia in adult healthy patients. Tanta Med J 2019;47:33-8
|How to cite this URL:|
Elgohary MM, El Badawy AAH, Elgebaly AS, Nassar WA. Comparative study between cisatracurium, atracurium as an adjuvant agent to local anesthetics on peribulbar anesthesia in adult healthy patients. Tanta Med J [serial online] 2019 [cited 2020 Nov 30];47:33-8. Available from: http://www.tdj.eg.net/text.asp?2019/47/1/33/267018
| Introduction|| |
Ophthalmic surgery is one of the most frequent surgical procedures requiring anesthesia in developed countries . Perioperative morbidity and mortality rates associated with eye (e.g. cataract) surgery are low . Nevertheless, because patients with cataracts tend to be older and to have serious comorbidities , systematic preoperative evaluation should be performed to consider a patient eligible for surgery. Anesthetic management may contribute to the success or failure of ophthalmic surgery . There is evidence that local anesthetic (LA) causes fewer adverse events than general anesthesia as well as reduces the recovery time of the patient .
There are different approaches to the delivery of local injection anesthesia for cataract surgery. The two main approaches are retrobulbar and peribulbar. The retrobulbar approach appears to be more commonly practiced. This block can provide adequate anesthesia, akinesia, and control of intraocular pressure (IOP) as well as postoperative analgesia . The most fearful complications with this technique are globe perforation, brain stem anesthesia, and retrobulbar hemorrhage, which is the most frequent complication and occurs in 1% of the cases ,,.
Many believe that the peribulbar block is a safer technique, but to produce akinesia a larger volume of anesthetic solution is required. In addition, the development of akinesia takes longer and is more frequently inadequate after peribulbar injections compared with retrobulbar injection .
To overcome these limitations, many adjuvant drugs , such as adrenaline, sodium bicarbonate, and hyaluronidase have been added to the LA mixture used for peribulbar block to augment its efficacy and hasten its speed of onset; however, their effects have been variable. Neuromuscular blocking drugs have also been added to the LA mixture and have been shown to improve the quality of peribulbar anesthesia ,.
| Aim and objective|| |
The aim of the study was to compare the effect of using atracurium, cisatracurium, as adjuvant agents to the LA substance on peribulbar anesthesia in cataract surgeries.
| Patients and methods|| |
This study was carried out on 90 adult patients of both sexes, American Society of Anaesthesiology I–II physical status scheduled for cataract surgery using peribulbar anesthesia in the Tanta University Hospital Ophthalmology Department, after obtaining approval of the local ethics committee and written consent was obtained from the patients after they were adequately informed about the procedure.
A total of 90 patients were randomly divided into three equal groups. Using a computer-generated randomization schedule and serially numbered, opaque, sealed envelopes, the patients were randomly allocated to one of the following three study groups:
- Group I (control group, N=30 patients): patients of this group received a combination of 4 ml bupivacaine 0.5%, 4 ml lidocaine 2% plus 0.5 ml normal saline.
- Group II (atracurium group, N=30 patients): patients of this group received 4 ml bupivacaine 0.5% and 4 ml lidocaine 2% plus 0.5 ml atracurium (5 mg).
- Group III (cisatracurium group, N=30 patients): patients of this group received 4 ml bupivacaine 0.5%, 4 ml lidocaine 2% plus 0.5 ml cisatracurium (1 mg).
Prior to performance of the block, a blinded observer evaluate the patient’s eyelid and ocular movement at the site of surgery. The block was done by anesthesiologist who was unaware of the nature of the solution injected.
Patient refusal, patients with renal or hepatic disease, cardiovascular instability, chronic cough, orthopnea, coagulopathy, high myopia, axial length of the globe greater than 26 mm, posterior staphyloma, local infection at the site of the block, extraocular muscles or eyelid abnormalities, complicated vitreous hemorrhage or retinal detachment and allergy to LAs were excluded from the study.
Preoperatively, all patients had full clinical examination and laboratory investigations as regards complete blood count, coagulation profile, metabolic profile as well as ECG, and chest radiography were done. Also complete ophthalmological examination as regards best corrected visual acuity on Snellen’s chart, IOP measurement by Goldman’s applanation tonometer, fundus examination using indirect ophthalmoscopy, axial length of the globe, and ocular contour examination using A and B scan ocular ultrasonography. Detailed anesthetic technique was explained to the patient on the preoperative visit.
On arrival at the operation theater, routine monitoring was done in the form of automated noninvasive blood pressure, pulse oximetry, and ECG. All the baseline parameters were observed and recorded. A good venous access was secured with 20 G cannula; O2 (2 l/min) was administered through the nasal cannula and premedications (1 mg midazolam, 25 µg fentanyl) were given to all patients.
All patients were comfortable in supine position and soft pads were placed under the pressure areas. A 27-G, 12-mm needle was used to inject 0.5 ml of lidocaine 2% through the conjunctiva and infratemporally just posterior to the inferior tarsal plate to anesthetize the conjunctiva.
After 15 s, 25-G, 25-mm needle with a sharp bevel was used to inject the study drug infratemporally transconjunctivally at the junction between the lateral third and medial two-thirds of the inferior orbital rim. The needle was directed vertically backward, parallel to the floor of the orbit. The depth of insertion of the needle was limited to 25 mm. The tip of the needle was extraconal close to the orbital wall beyond the equator of the globe, but anterior to the posterior border of the globe in the peribulbar space.
The patient was asked to move the eye before injection of the anesthetic solution. After aspiration, 4.25 ml of the LA solution was injected. A second transconjunctival injection of the LA solution (4.25 ml) was performed medial to the lacrimal caruncle. This was followed by gentle massage for 30 s to facilitate the spread of the LA mixture.
Injection of the intended volume of the study drug stopped when there was fullness of the orbit and/or drooping of the upper eyelid during injection.
Intermittent digital compression with a soft pad was applied to the eye to lower IOP until sufficient motor blockade occurred. Corneal anesthesia was also evaluated using a small cotton wool. To assess ocular akinesia, the patients were asked to look in four directions: lateral, medial, superior, and inferior. Ocular movement in each direction was scored as 2 if it is normal, 1 if it is limited, and 0 if there was no movement (total score: 0–8). The patient was also asked to forcefully close his/her eyes to assess the orbicularis oculi muscle on a scale 0–2 (0=complete akinesia, 1=partial, 2=normal movement). If adequate condition to begin surgery was not obtained 10 min after performing the block, supplemental injection with 2 ml of lidocaine 2% either infratemporally or medially was administered.
The signs of successful block were dropping of the upper lid with inability to open the eyes (ptosis), absent eye movement in all four directions (akinesia), and inability to fully close the eye once opened.
Assessment of demographic data and onset time of corneal anesthesia were done. IOP was measured using Schiotz tonometer prelocal injection and 10 min after local injection; time to adequate condition to begin surgery is defined as the presence of corneal anesthesia together with ocular movement score of less than or equal to 1 and eyelid squeezing score of 0, the score of akinesia in each direction in the 1, 3, 5, 7, and 10 min after injection score (0=total, score 1=relative, score 2=no akinesia) (total score: 0–8), eyelid squeezing score in the 1, 3, 5, 7, and 10 min (score 0=total akinesia, 1=relative, 2=normal movement), number of patients requiring supplementary injection, the offset time of akinesia in the recovery unit; intraoperative pain was assessed at the end of surgery using visual analog scale 0 being no pain and 10 being the worst imaginable pain. The surgeon’s satisfaction (blinded to group assignment) was assessed using a satisfaction verbal rating scale from 0 (total dissatisfaction) to 10 (total satisfaction), recording of complications such as chemosis, conjunctival hemorrhage, raised pressure, diplopia, and ptosis. Serious complications such as those caused by local trauma (globe perforation, retrobulbar hemorrhage, and muscle damage) or systemic effects of the local anesthetic (overdose, intravascular injection, and subarachnoid spread) were recorded.
| Results|| |
Demographic data were comparable with insignificant difference in age, sex, weight, American Society of Anaesthesiology physical status, axial length of the globe, and duration of surgery ([Table 1]). Onset time of corneal anesthesia in group I (1.60±0.77), group II (1.47±0.68), and group III (1.70±0.75) were statistically insignificant (P>0.05). Measurement of IOP preinjection and 10 min postinjection in group I (11.01±2.16 and 13.65±2.29), group II (11.20±2.11 and 13.69±1.97), and group III (11.25±2.19 and 13.79±1.95), respectively, were statistically insignificant (P>0.05; [Table 2]).
|Table 2 Onset time of corneal anesthesia and measurement of intraocular pressure|
Click here to view
There was a significant increase in time to begin surgery in group I (9.83±3.34) when compared with group II (5.70±3.06) and group III (6.70±2.98) (P=0.001).
There was a statistically significant difference (P=0.001) in akinesia score at 1, 3, 5, 7, and 10 min between group I (7.17±0.79, 5.17±1.51, 3.53±1.59, 2.00±1.80, and 1.07±1.36), group II (3.90±1.32, 1.97±1.52, 0.67±0.99, 0.37±0.76, and 0.30±0.75), and group III (4.53±1.14, 2.53±1.48, 1.07±1.11, 0.53±0.86, and 0.37±0.72), respectively ([Table 3]).
Also, there was a statistically significant difference (P=0.001) in eyelid squeezing score at 1, 3, 5, 7, and 10 min between group I (2.00±0.00, 1.67±0.48, 0.83±0.53, 0.33±0.48, and 0.20±0.41), group II (1.63±0.49, 0.70±0.47, 0.23±0.43, 0.07±0.25, and 0.07±0.25), and group III (1.73±0.45, 0.97±0.61, 0.33±0.55, 0.10±0.31, and 0.07±0.25), respectively ([Table 4]).
There was increased number of patients who required a supplementary dose in group I (33.3%) than in group II (10%) and group III (10%) (P=0.024).
Rapid offset of akinesia occurred in group I (69.0±8.75) than in group II (99.67±9.99) and group III (100.33±9.46) (P=0.001).
Intraoperative pain using the visual analog scale score was statistically insignificant (P>0.05) between group I (1.73±2.16), group II (1.27±1.59), and group III (1.27±1.72).
Satisfaction verbal rating scale was statistically lower (P=0.042) in group I (8.53±1.81) than in group II (9.30±1.02) and group III (9.20±1.19).
There was no statistical difference between groups I, II, and III regarding complications and adverse effects (such as chemosis, pain, conjunctival hemorrhage, globe perforation, retrobulbar hemorrhage, intravascular injection, subarachnoid spread, and overdose of muscle relaxants).
| Discussion|| |
The trend toward LA in preference to general anesthesia in eye surgery increase apace for several reasons not least of which is the move toward day-case surgery .
Currently, there are several techniques including retrobulbar, peribulbar, sub-Tenon’s, and subconjunctival, and some surgeons perform cataract surgery only with topical anesthesia. The question which exercises the mind is the simplest, most effective, and safest procedure for LA .
The increasing use of peribulbar anesthesia can be partly attributed to its reputation for reduced risk of complications including retrobulbar hemorrhage, globe perforation, optic nerve injury, and respiratory arrest from brain stem anesthesia. Also peribulbar anesthesia is used with good effect in most forms of ocular surgery including retinal detachment surgery .
Critics of peribulbar anesthesia are a lower rate of adequate block and delayed onset of anesthesia, the possible need for multiple injections and a large dose of anesthetic drugs resulting in tight orbit .
The use of adjuvants to LAs for ophthalmic regional anesthesia focuses on the efficacy of the adjuvants improving akinesia, speed of onset, and reducing block failure .
Our study results showed that the addition of muscle relaxant (atracurium or cisatracurium) in peribulbar anesthesia provide better akinesia, rapid onset, and more prolonged time of akinesia. It also decreases the need for supplementary injection. The main finding of this study was that atracurium and cisatracurium groups demonstrated significantly better akinesia score at 1, 3, 5, 7, and 10 min postinjection, rapid onset of akinesia, and more prolonged time of akinesia than the control group.
Neuromuscular blocking drugs have been added to the LA mixture and have been shown to improve the quality of peribulbar anesthesia because of its effect on motor nerves. It induces akinesia in extraocular muscles and orbicularis occuli thereby optimizing the setting for ophthalmic surgeries .
Addition of muscle relaxants to peribulbar anesthesia was reported in many studies before; Küçükyavuz and Arici  reported that the effect of 8 ml of a lidocaine–bupivacaine mixture plus 0.5 ml (5 mg) atracurium was better than the 8 ml of the same LA mixture plus 0.5 ml 0.9% NaCl so that mixing of atracurium to LAs enhanced the onset of akinesia and provided better condition without adverse events.
Aissaoui et al.  reported that the addition of rocuronium to a LA mixture improves the akinesia score. Also, Mehrdad et al.  reported that the onset akinesia is accelerated by the adding atracurium and cisatracurium to the LA mixture; also, he found that 92.6 and 85.2% of the patients in the atracurium and cisatracurium groups, respectively, after 10 min underwent the total akinesia and he found that adding a low-dose atracurium or cisatracurium to the anesthetic drug is recommended in order to accelerate the onset of akinesia resulted by the peribulbar block and in order to enhance the quality of akinesia.
Reah et al.  who studied the effects of the addition of 0.5 mg of vecuronium bromide to standard LA mixture used for peribulbar anesthesia on 60 patients undergoing regional anesthesia for intraocular surgery reported that the eye movement assessed at both 5 and 10 min were significantly reduced in the vecuronium added group.
Another study was done by Abdal Maboud et al.  who evaluated the effect of addition of 0.5 ml atracurium to a mixture of fentanyl and both xylocaine and bupivacaine LAs in retrobulbar anesthesia in patients undergoing surgery for retinal detachment and reported that there was a statistically significant difference between the two groups in the onset of globe akinesia where only 39.9% of patients in the control group got a complete akinesia at 3 min; whereas in the fentanyl atracurium group 100% of patients got a complete akinesia at 3 min and so atracurium used as an adjuvant to LAs provided better akinesia, hence optimizing the setting for ophthalmic surgeries especially those involving extraocular muscles like in squint and retinal detachment.
As regards offset time of akinesia, our results have shown significant increase in time of akinesia in atracuriam and cisatracurium groups when compared with the control group with insignificant difference between atracurium and cisatracuriun groups.
Our study was in agreement with Eghbal et al.  who conducted a study on 64 patients scheduled for cataract surgery under LA with or without the addition of atracurium. The onset of complete akinesia was quicker and duration longer in the atracurium group than in the control group. The study concluded that muscle relaxant as an adjuvant shortened the onset period of retrobulbar block, prolonged its duration, and provided excellent surgical conditions without any specific complications.
As regards measurement of IOP by using Schiotz tonometer, our results have shown insignificant differences between the three studied groups, but there was significant increase in IOP in comparison between preinjection and 10 min postinjection of anesthetic solution in the same group. The transient increase in IOP after 10 min was due to injection of LAs in a limited space.Our results were in agreement with Alster et al.  who reported that the mechanism of increased IOP is related to the mechanical pressure effect from the volume injected; a smaller volume (6 ml) was used in their study. This volume was associated with transient increase in IOP with no operative pain.
The present study results was in agreement with Donlon , who reported that when the patient was anesthetized with ropivacaine or lidocaine, there was an increase in IOP during 1 min after injection as peribulbar anesthesia itself cause a transient increase in IOP, secondary to injection of anesthetic solution in the orbital space.
Also Stevens et al.  found a greater rise in IOP using peribulbar anesthesia as compared with retrobulbar or sub-Tenon’s anesthesia and they attribute this to the greater volume used in the peribulbar technique.
This study results was in disagreement with Abdal Maboud et al.  who reported that using atracurium was associated with a clinically significant drop of IOP of average 1.2 mmHg and he explained this by the relaxation of the extraocular muscles which play that role in IOP.
The present study results was in agreement with Saunders et al.  who reported that peribulbar block has comparatively less incidence of major complications. Also, Mehrdad et al.  who reported that there was no ocular or systemic toxicity followed by the topical injection of the local relaxants during or after the LA.
| Conclusion|| |
Addition of muscle relaxant (atracurium or cisatracurium) in peribulbar anesthesia provides better akinesia, rapid onset, and more prolonged time of akinesia It also decreases the need for supplementary injection.
| Authors’ Contributions|| |
All authors had equal role in the design, work, statistical analysis, and manuscript writing.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]