by CRNA2B


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how about succs and IOP? and how does it happen (2)

›Succ  = increased IOP !!!!!!!!
  • ›Can increase IOP by 6-9 mmHg within 4 minutes & lasts 7 minutes
  • ›Increase IOP d/t tonic contraction of extraocular muscles, relaxation of orbital smooth muscle, choroidal vascular dilation and cycloplegia
what meds u can use w succs to decrease IOP?
›Pretreat with NDMB, BBs & acetazolamide
what is Oculcardiac reflex or Aschner reflex? ›

›Oculcardiac reflex or Aschner reflex
  • ›Caused by pressure on the globe, ocular manipulation, or traction on extraocular muscles (strabismus surgery causes traction on the medial rectus)
  • Can occur in 15-80% of cases
What cranial nerves carry impulses for the oculocardiac reflex?
what are the cardiac effects of oculocardiac reflex?
›Results in bradycardia, junctional rhythm, and PVCs
ocularcardiac reflex is common in what surgery?
›Most common with strabismus surgery in peds
what can cause ocularcardiac reflex (something we do in anesthesia)?
›Hypercarbia, hypoxemia & light anesthesia = higher incidence
how do you manage oculocardiac reflex?
  • ›Notify surgeon
  • ›Release simulation
  • ›Deepen anesthesia
  • ›IV atropine/ glyco (›Prophylactic is not 100% effective prevention)
  • ›Infiltration of LA
what is strabismus?

›Poor alignment of the visual axis or “crossed eyes”
what does strabismus lead to?
›May lead to double vision ›
what pt population is affected by strabismus?
Usually in children
how is strabismus corrected?
›Corrected with surgery on the extraocular muscles
what are 3 anesthesia problems associated w strabismus?
  • ›Possible increased risk of malignant hyperthermia
  • ›High incidence of post-operative nausea and vomiting
  • ›Likelihood of an oculocardiac reflex
what med is contraindicated w strabismus and why/

›No sux b/c this may cause tonic contractures of extraocular muscles
what is common post op problem w strabismus?

›Post-operative nausea and vomiting
what are the ways to prevent post op N/V w strabismus?
  • ›Minimal use of opioids
  • ›Propofol
  • ›Decrease or avoid N2O
  • ›5-HT3 receptor antagonist (ex. Zofran 0.1 mg/kg IV)
  • Steroids
  • ›Decompress stomach
  • ›Maintain adequate hydration
  • ›Placement of lidocaine near the extraocular muscle during surgery
what retrobulbar block (RBB) is used for?

›Regional anesthesia for the eye
where is LA injected w RBB?

›LA injected behind the eye into the cone formed by the extraocular muscles
what is blocked w RBB?

›The retrobulbar block is aimed at blocking the ciliary ganglion, ciliary nerves, and cranial nerves II, III, and VI.  This is accomplished by delivering the LA into the muscle cone itself.
what are the complications w RBB (9)?

  • ›Stimulation of oculocardiac reflex
  • ›Retrobulbar bleeding (most common)
  • ›Puncture of ocular globe
  • ›Retinal detachment
  • ›Retinal artery occlusion
  • ›Optic nerve damage
  • Total spinal
  • ›Intraocular injection
  • ›Post-retrobulbar apnea syndrome (›Accidental spread into CSF)
what kind of induction is appropriate for ocular surgery/
smooth
what things to consider w anesthesia w ocular surgery?

  • ›NDMB vs DMB
  • Oculocardiac reflex?
  • ›Pay attention to ETCO2
what position is good for ocular surgery? and why?
›Reverse trendelenburg bcs it Decreases CVP
w ocular surgery ___ anesthesia is bad
  • ›Adequate pain/anesthetic level›
  • Light anesthesia is bad
why is it importatnt to give anti emetic w ocular surgery?
Valsalva during vomiting = increased CVP
what are the effects of hypotension w ocular surgery/

›Hypotension can = hypoperfusion to optic nerve
what about emergence w ocular surgery?

›Smoothest emergence ever!!!!???
what is the problem w some eye drops?

›Opthalmic BBs can produce atropine resistant bradycardia & bronchospasm
what about echothiophate drops?
›Miosis inducing anticholinesterase (prolongs sux metabolism)
what is cataract?

›Cataracts are the opaque, or milky, areas that can form in part or all of the crystaline lens of the eye. They often start with only a slight disturbance of normal vision, often going unnoticed for years, and can slowly increase in opacity until they completely interfere with vision.
how do you fix cataract?
›The surgery removes the old lens and replaces it with a plastic one, referred to as an intraocular lens.
what is diabetic retinopathy/

›Diabetic Retinopathy occurs as a result of elevated blood glucose levels. The increased levels of glucose damage blood vessels, and diabetic retinopathy damages the tiny blood vessels of the retina.
what is proliferated retinopathy?
›During the more advanced stage of the disease (DM), called proliferative retinopathy, more bleeding and leakage of fluids occurs, as well as the growth of new, abnormal, capillaries. These new capillaries are weak and also tend to bleed, bulge, or become blocked. It is during this stage that sudden and severe vision loss may occur. 
what is retinal detachment?

›Retinal Detachment occurs when the retina breaks, tears, or develops a hole. Fluid from the vitreous will then seep in through the tear or hole and cause the retina to detach from its pigment epithelial layer.
who does retinal detachment effect? and what are s/sx?
They most often occur in the elderly, nearsighted, those who have an advanced stage of retinopathy or other retinal disease, those who have had cataract surgery, or those who have experienced trauma. Sudden vision changes such as floaters, blurry or distorted central vision, flashes of light, or “shadows” that sweep inward from the periphery might indicate a rhegmatogenous retinal detachment.

how do the fix retinal detachment?

  • ›Utilize intraocular gas expansion
  • Gas bubble is injected into the posterior chamber.

what gas is contraindicated w retinal detachment surgery? why?

  • ›Do not use N2O during retinal detachment surgery b/c a bubble of sulfur hexafluoride (SF6) is used
  • Remember, N20 is 35 X more soluble than nitrogen in blood
what is macular degeneration?

›Age related macular degeneration is a medical condition which usually affects older adults that results in a loss of vision in the center of the visual field (the macula) because of damage to the retina. It occurs in “dry” and “wet” forms. It is a major cause of visual impairment in older adults (>50 years).
what is the tx of macular degeneration?
no treatment
what is glaucoma?

›A disease in which the optic nerve is damaged, leading to progressive, irreversible loss of vision. It is often, but not always, associated with increased pressure of the fluid in the eye
what is closed angle glaucoma?
›Closed angle glaucoma can appear suddenly and is often painful; visual loss can progress quickly but the discomfort often leads patients to seek medical attention before permanent damage occurs.
what is open angle glaucoma?
›Open angle: chronic glaucoma tends to progress at a slower rate and the patient may not notice that they have lost vision until the disease has progressed significantly.
what is the tx for glaucoma(3)?
  • beta-blockers (timolol)
  • alpha-2 agonists (brimonidine)
  • parasympathomimetics (prilocaine/ecothiopate)
how does timolol work?
  • beta-blockers (timolol) which decrease aqueous humor production,
how do alpha 2 agonist work?
  • alpha-2 agonists (brimonidine)- decrease AH production and increase trabecular outflow, parasympathomimetics (pilocarpine/ecothiopate) which contract ciliary muscle to allow increased outflow
how do parasympathomimetics work?
parasympathomimetics (pilocarpine/ecothiopate) which contract ciliary muscle to allow increased outflow
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