Anesthetic Impacts on the Oculocardiac Reflex: Evidence from a Large, Observational Study

Robert W Arnold,1 Stephen Jansen,2 Joseph C Seelig,2 Mikhail Glasionov,3 Russell E Biggs,2 Brion Beerle2 1Alaska Children’s EYE & Strabismus, Anchorage, AK, 99508, USA; 2Chugach Anesthesia Group, Anchorage, AK, USA; 3Department of Anesthesia, Alaska Regional Hospital, Anchorage, AK...

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Autores principales:	Arnold RW, Jansen S, Seelig JC, Glasionov M, Biggs RE, Beerle B
Formato:	article
Lenguaje:	EN
Publicado:	Dove Medical Press 2021
Materias:	oculocardiac reflex trigeminovagal strabismus surgery opioids dexmedetomidine dexamethasone anticholinergics Ophthalmology RE1-994
Acceso en línea:	https://doaj.org/article/aa0dd1283782463997ea34f1ad1cafd2
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spelling	oai:doaj.org-article:aa0dd1283782463997ea34f1ad1cafd22021-12-02T14:20:37ZAnesthetic Impacts on the Oculocardiac Reflex: Evidence from a Large, Observational Study1177-5483https://doaj.org/article/aa0dd1283782463997ea34f1ad1cafd22021-03-01T00:00:00Zhttps://www.dovepress.com/anesthetic-impacts-on-the-oculocardiac-reflex-evidence-from-a-large-ob-peer-reviewed-article-OPTHhttps://doaj.org/toc/1177-5483Robert W Arnold,1 Stephen Jansen,2 Joseph C Seelig,2 Mikhail Glasionov,3 Russell E Biggs,2 Brion Beerle2 1Alaska Children’s EYE & Strabismus, Anchorage, AK, 99508, USA; 2Chugach Anesthesia Group, Anchorage, AK, USA; 3Department of Anesthesia, Alaska Regional Hospital, Anchorage, AK, USACorrespondence: Robert W ArnoldAlaska Blind Child Discovery, Alaska Children’s EYE & Strabismus, 3500 Latouche #280, Anchorage, AK, 99508, USATel +1 907 561-1917Fax +1 907 563-5373Email eyedoc@alaska.netBackground: The oculocardiac reflex (OCR) is a sudden vagal bradycardia that can be elicited by traction on an extraocular muscle. Bradycardia is highly variable from case to case necessitating a large sample size to observe small to moderate impact on OCR. While the surgeon’s tissue manipulation has immediate impact on OCR and individual patients may have some proclivity to OCR, we sought to characterize the impact on OCR by the anesthesiologist.Methods: From 1992 to 2019, during routine, community outpatient general anesthetic strabismus surgery, oculocardiac reflex was prospectively observed utilizing a uniform 10-second, 200 gram square wave tension on each extraocular muscle. Anesthetic parameters were recorded and analyzed with double-cohort design and non-parametric statistics and correlations. We define %OCR as the maximally tension-altered heart rate and a percent of stable pre-tension heart rate.Results: The median (IQR) confidence intervals OCR for 2527 initial cases was 89% (67% to 97%) without anticholinergic, and 99% (95% to 100%) in 165 patients with anticholinergic. OCR was 81% (62% to 96%) in 1034 with opioids and to 75% (60% to 95%) in 59 with dexmedetomidine and in 189 with IV dexamethasone to 72% (56% to 92%) There was a significant (p< 0.01 Kruskal–Wallis) impact on OCR by various opioids, muscle relaxants and inhalational agents. Linear regression showed significant inhibitory impact on OCR by increased inhalational agent depth and by lower exhaled CO2.Conclusion: The anesthesiologist can block OCR with sufficient anticholinergics, deeper inhalational agents and robust ventilation, and can augment OCR with opioids, dexmedetomidine and apparently also with dexamethasone.Clinical Trials Registry: NCT04353960.Keywords: oculocardiac reflex, trigeminovagal, strabismus surgery, opioids, dexmedetomidine, dexamethasone, anticholinergicsArnold RWJansen SSeelig JCGlasionov MBiggs REBeerle BDove Medical Pressarticleoculocardiac reflextrigeminovagalstrabismus surgeryopioidsdexmedetomidinedexamethasoneanticholinergicsOphthalmologyRE1-994ENClinical Ophthalmology, Vol Volume 15, Pp 973-981 (2021)
institution	DOAJ
collection	DOAJ
language	EN
topic	oculocardiac reflex trigeminovagal strabismus surgery opioids dexmedetomidine dexamethasone anticholinergics Ophthalmology RE1-994
spellingShingle	oculocardiac reflex trigeminovagal strabismus surgery opioids dexmedetomidine dexamethasone anticholinergics Ophthalmology RE1-994 Arnold RW Jansen S Seelig JC Glasionov M Biggs RE Beerle B Anesthetic Impacts on the Oculocardiac Reflex: Evidence from a Large, Observational Study
description	Robert W Arnold,1 Stephen Jansen,2 Joseph C Seelig,2 Mikhail Glasionov,3 Russell E Biggs,2 Brion Beerle2 1Alaska Children’s EYE & Strabismus, Anchorage, AK, 99508, USA; 2Chugach Anesthesia Group, Anchorage, AK, USA; 3Department of Anesthesia, Alaska Regional Hospital, Anchorage, AK, USACorrespondence: Robert W ArnoldAlaska Blind Child Discovery, Alaska Children’s EYE & Strabismus, 3500 Latouche #280, Anchorage, AK, 99508, USATel +1 907 561-1917Fax +1 907 563-5373Email eyedoc@alaska.netBackground: The oculocardiac reflex (OCR) is a sudden vagal bradycardia that can be elicited by traction on an extraocular muscle. Bradycardia is highly variable from case to case necessitating a large sample size to observe small to moderate impact on OCR. While the surgeon’s tissue manipulation has immediate impact on OCR and individual patients may have some proclivity to OCR, we sought to characterize the impact on OCR by the anesthesiologist.Methods: From 1992 to 2019, during routine, community outpatient general anesthetic strabismus surgery, oculocardiac reflex was prospectively observed utilizing a uniform 10-second, 200 gram square wave tension on each extraocular muscle. Anesthetic parameters were recorded and analyzed with double-cohort design and non-parametric statistics and correlations. We define %OCR as the maximally tension-altered heart rate and a percent of stable pre-tension heart rate.Results: The median (IQR) confidence intervals OCR for 2527 initial cases was 89% (67% to 97%) without anticholinergic, and 99% (95% to 100%) in 165 patients with anticholinergic. OCR was 81% (62% to 96%) in 1034 with opioids and to 75% (60% to 95%) in 59 with dexmedetomidine and in 189 with IV dexamethasone to 72% (56% to 92%) There was a significant (p< 0.01 Kruskal–Wallis) impact on OCR by various opioids, muscle relaxants and inhalational agents. Linear regression showed significant inhibitory impact on OCR by increased inhalational agent depth and by lower exhaled CO2.Conclusion: The anesthesiologist can block OCR with sufficient anticholinergics, deeper inhalational agents and robust ventilation, and can augment OCR with opioids, dexmedetomidine and apparently also with dexamethasone.Clinical Trials Registry: NCT04353960.Keywords: oculocardiac reflex, trigeminovagal, strabismus surgery, opioids, dexmedetomidine, dexamethasone, anticholinergics
format	article
author	Arnold RW Jansen S Seelig JC Glasionov M Biggs RE Beerle B
author_facet	Arnold RW Jansen S Seelig JC Glasionov M Biggs RE Beerle B
author_sort	Arnold RW
title	Anesthetic Impacts on the Oculocardiac Reflex: Evidence from a Large, Observational Study
title_short	Anesthetic Impacts on the Oculocardiac Reflex: Evidence from a Large, Observational Study
title_full	Anesthetic Impacts on the Oculocardiac Reflex: Evidence from a Large, Observational Study
title_fullStr	Anesthetic Impacts on the Oculocardiac Reflex: Evidence from a Large, Observational Study
title_full_unstemmed	Anesthetic Impacts on the Oculocardiac Reflex: Evidence from a Large, Observational Study
title_sort	anesthetic impacts on the oculocardiac reflex: evidence from a large, observational study
publisher	Dove Medical Press
publishDate	2021
url	https://doaj.org/article/aa0dd1283782463997ea34f1ad1cafd2
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Anesthetic Impacts on the Oculocardiac Reflex: Evidence from a Large, Observational Study

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