Pediatric Cataract Surgery Suresh K Pandey, Frank A Billson, Elie Dahan, Howard V Gimbel
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1Anesthetic Consideration2

Anesthesia for Pediatric Cataract SurgeryChapter 1

Giorgia Ferro
Maria Sammartino
4
 
INTRODUCTION
Anesthesia for pediatric cataract surgery particularly in early months of life requires special training in pediatric anesthesia. Specialized anesthetic equipment, and anesthetics if the infant's life is not to be compromised. It is predictably a general anesthesia that can be associated to a local technique to control postoperative pain (blended anesthesia). Considering that cataract can be associated with different congenital syndromes, children included in this group have to be carefully investigated prior to surgery because congenital heart diseases, neuromuscular, hepatorenal disorders and craniofacial deformities can affect the anesthetic plan (Table 1.1).
 
PREOPERATIVE ASSESSMENT
Anesthetic assessment for pediatric cataract surgery should include the history (obtained by parents or parent guardian) for previous anesthetics, allergies, bronchial asthma and other known disorders previously detected in the child. Family history for anesthetic-related deaths or perioperative fever is mandatory to consider an increased risk of malignant hyperthermia.
Current medications taken by the child have to be listed considering that corticosteroids and anticonvulsants can interfere with the anesthetic plan and some of those have to be ceased or changed.1
In the last few years, routine preoperative lab investigations, such as electrolytes, urea, creatinine, blood sugar level, full blood count, coags, urinalysis, electrocardiogram (ECG) and chest X-ray have lost importance for the assessment of a child prior to anesthetics.5
Table 1.1   Specific abnormalities associated with congenital cataract
Idiopathic
  • Infectious:
    • German measles
    • Herpes simplex
    • Cytomegalovirus
    • Treponema pallidum
    • Toxoplasmosis
  • Metabolic disorders:
    • Hypoglycemia
    • Hypokalemia
    • Galactokinasis deficiency
    • Galactosemia
    • Fabry syndrome
  • Nonmetabolic disorders:
    • Wolf-Hirschhorn syndrome
    • Hallermann-Streiff syndrome
    • Marfan syndrome
    • Alport syndrome
    • Lowe syndrome
    • Conradi syndrome
  • Steinert syndrome
  • Patau syndrome
  • Edward's syndrome
  • Stickler syndrome
  • Zellweger Morbus syndrome
Other systemic disorders:
  • Asthma
  • Arthritis
  • Lupus
  • Leukemia
  • Crohn's disease
Chromosomal impairment:
  • Down syndrome
  • Pierre Robin syndrome
  • Treacher-Collins syndrome
  • Goldenhar syndrome
  • Turner's syndrome
Prematurity
Post-traumatic
Diabetes
Radiation
International studies have shown the possibility to abandon a systematic prescription of complementary tests in favor of an increased selectivity based on information obtained during the interview with parents.2,3
A history of prematurity or ventilation intubation in a neonatal intensive care unit could suggest the possibility 6of associated airway abnormalities and increased anesthetic risk. Upper airway infections increase the risk to develop respiratory complications such as bronchospasm and laryngospasm or pneumonia and this risk is much higher when orotracheal intubation has to be performed. An acute infection associated with purulent sputum and cough delays surgery up to 7 weeks.
Cleft lip and palate, macroglossia, micrognathia, instability of the atlantic-occipital joint due to a laxity of the ligaments (such as in Down's syndrome) and other rare craniofacial abnormalities have to be considered not only for difficult intubation protocols but also for position-related injuries during general anesthesia.
Fasting rules for pediatric patients include stopping clear fluids (water, camomile and tea) 2 hours before surgery, milk and breastfeeding 4 hours before in neonates and infants and 6 hours in older children. Table 1.1 includes causes of congenital cataract; and so, associated disorders with specific abnormalities that have to be considered during the preoperative anesthetic assessment (Figs 1.1 to 1.3).
 
PREMEDICATION
Premedication is part of the anesthesia and it has to be administered as prescribed by the anesthetist half an hour prior to surgery while the patient is still under the care of ward nurses and parents in order to reduce the OT-related stress and the trauma of parent's absence. Now-a-days, oral medications are the best choice and are usually mixed with flavored solutions (mainly strawberry and chocolate) to cover their bitter taste (Fig. 1.4).47
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FIGURE 1.1: Photograph of an infant with Wolf-Hirschhorn syndrome (WHS).
This is characterized by typical craniofacial features in infancy consisting of “Greek warrior helmet appearance” of the nose, high forehead with prominent glabella, ocular hypertelorism, highly arched eyebrows, short philtrum, downturned mouth, and micrognathia. Congenital cataract may present as associated ocular anomaly
At this stage, topical application of anesthetic cream may allow intravenous cannulation in awake collaborating children.8
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FIGURE 1.2: Congenital cataract may be associated with Goldenhar's syndrome.
Goldenhar's syndrome is a triad of anomalies including ocular epibulbar dermoids, anomalies of the ear and vertebral anomalies. It is a sporadic, non-hereditary syndrome detected in infancy
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FIGURE 1.3: Photograph of a case of Goldenhar's syndrome showing external ear tags and micrognathia
9
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FIGURE 1.4: Oral medications for premedications are usually mixed with flavored solutions such as strawberry and to cover their bitter taste, as shown in the figure
 
ANESTHESIA
Induction of general anesthesia is mainly inhalatory in preverbal children, when the insertion of a venous cannula can be difficult and frightened for the child. Ability to gain the child trust is important and topical anesthetic cream is helpful in this as presence of the parents. An intravenous induction is often possible. When the child is capable to understand and the topical anesthetic cream has been applied, it is possible to discuss the choice of intravenous or inhalatory induction. In developed countries, Sevoflurane is the vapor of choice for inhalatory induction in 10children because of its low irritating effect on upper airways. Propofol, an intravenous anesthetic, and Remifentanil, a short-acting recent opioid, are now-a-days often used in combination for continuous infusion to perform total intravenous anesthesia (TIVA) in the adult patient. These drugs are suitable for pediatric anesthesia because of the rapid clearance and recovery and their use is promoted in recent publications and studies even if they are not yet formally approved all over the world for the use in extremely young children as prematures or neonates younger than 1 month (Fig. 1.5).5
Balanced anesthesia associates intravenous medications with alogenated vapors and it is normally used for children.
Orotracheal intubation is of choice for pediatric cataract surgery because the face of the child is always completely covered by surgical drapes and the dislocation of any other ventilatory device is more likely to be.
The use of laryngeal mask airway (LMA) has been reported and may reduce the incidence of lower airway infections in children with increased susceptibility. It may be used also as emergency device when orotracheal intubation is impossible. Cuffed oropharyngeal airway (COPA) has also been used by the authors and is part of the skills for pediatric anesthesia.6
General anesthesia can be associated with local anesthesia (blended anesthesia) and this may permit lighter general anesthesia in pediatric cataract surgery. This association is useful to obtain postoperative analgesia. In pediatric cataract surgery, it is usually achieved with peribulbar block.11
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FIGURE 1.5: Pre-oxygenation of an infant during the induction of a total intravenous anesthesia
The older retrobulbar block is not without risk of perforation of globe in infants. It is generally performed after the induction of general anesthesia by the anesthetist or the ophthalmologist, but it can be performed at the end of the surgery (Fig. 1.6).7,812
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FIGURE 1.6: General anesthesia can be associated with local anesthesia (blended anesthesia), which is useful to obtain postoperative analgesia. During the pediatric cataract surgery, it is usually achieved with peribulbar block as shown in the figure
Otherwise, analgesia can be achieved with the parenteral or per rectal administration of paracetamol + codeine or NSAID (nonsteroidal anti-inflammatory drug) or synthetic opioids just after the induction of the anesthesia (Table 1.2).
Pulse should be continuingly monitored and some surgeon prefer to do it manually in the facility to monitor vitals sign is not available. Administration of Atropine can be necessary to control bradycardia induced by oculocardiac reflex (OCR) due to trigeminovagal stimulation during extrinsic eye muscles traction, but atropine is not anymore given during the induction to prevent it.9-1113
Table 1.2   Pediatric doses of analgesics and NSAID
Paracetamol 125-250 mg suppositories
Paracetamol 125/250 mg + codeine 5 mg
Ketorolac 1 mg/kg
Ketoprofene 0.1-0.2 mg/kg
Tramadol 1-2 mg/kg
Morphine 0.1-0.2 mg/kg
Postoperative nausea and vomiting (PONV) are common complications of pediatric ophthalmic surgery and require the administration of proper antiemetics (such as metochlopramide or H3 antagonists) or of other drugs that exhibit antiemetic effect such as dexamethasone (corticosteroid) that acts by blocking PGE and by enhancing endorphines action. It is important to remember that propofol exhibited antiemetic properties if it is used throughout the surgery.1214
Maintenance of body temperature is very important in infancy, so that the use of a heating system (such as heated mattress or hot air pump) is advisable. The field where the baby lays needs to be preheated and a disposable transparent blanket should cover the whole body, while a disposable “hot air sausage” should be used to avoid penetration of cold air from the sides as shown in Fig 1.7.
Cataract surgery requires adequate anesthetic plan with minimal muscular relaxation and safe airway protection, since immediate access to the young patient is not easy for the anesthetist during the whole surgery. Orotracheal intubation remains the airway protection.14
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FIGURE 1.7: Disposable transparent blanket should cover the whole body of neonate. Note a disposable hot air sausage used to avoid penetration of cold air from the sides
Since technique of choice in most of the patients, even if recently LMA and COPA have been used.
During surgery if it is necessary to maintain normocapnia and moderate hypotension. Fluid management should usually include a mixed solution of normal saline and Dextrose 5%. Administration of fluids should be minimal and just to carry medication into bloodstream.
Monitoring of vital signs should include SaO2, heart rate, EtCO2 and body temperature for prematures and neonates.
Madan et al15 showed that orotracheal intubation increases intraocular pressure (IOP) in pediatric patients 15with or without glaucoma, but in the group with glaucoma, the IOP increase was significantly higher. These authors also showed that the increase of IOP is much higher at extubation and similar in both groups of young patients. So cough should be prevented when awakening the child.
Postoperative care includes lateral positioning of the child on the opposite side of the operated eye when possible.
Prevention of PONV is more frequent in postoperative period due to vasovagal hyper-response and it affects one third of pediatric patients aged more than 2 years undergoing ophthalmic surgery. This percentage doubles after strabism surgery. Strategies for treatment of PONV are listed in Table 1.3.1618
Table 1.3   Therapeutic strategies to treat PONV
  • Droperidol 50–75 γ/kg
  • Metoclopramide 0.15 γ/kg
  • Ondransetron 0.1 mg/kg
  • Granisetron 40 γ/kg
  • Tropisetron 0.1 mg/kg
  • Dexamethasone 0.1 mg/kg
If analgesia has not been achieved with regional block or administration of previously mentioned medications, morphine and other strategies could be useful for older children in the postoperative setting (Table 1.2).16
 
EDITOR'S NOTE
Drs. Ferro and Sammartino emphasize the special problem in pediatric anesthesia for cataract surgery in infancy and childhood necessitating special equipment, special training. Although neuroleptanalgesia using droperidol or fentanyl is useful in older children, popularity of ketamine has waned due to hallucinations and psychic phenomenon. Its duration is prolong after large intramuscular dosage. Ketamine finds its place many developing countries, where access to special anesthetic equipment is not possible and specialist training in pediatric anesthesia is still awaited. Before condemning it, there is need to approach to question with open mind recognizing that this procedure is made possible restoration of sight, where insistence on general anesthesia would have delayed surgery or even condemn the child to blindness.
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  1. 17 Sammartino M, Ferro G. Cuffed oropharyngeal airway: An option during paediatric ophthalmic surgery. Paed Anaesth 2002;12(6):559–560.
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