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Show /. Clin. Neurtl-tlphth.l1mol. I: 171-172, l<lt\ I. Editorial Retrobulbar Marcaine Can Cause Respiratory Arrest On fune ILl, ILl81.l1r. N.mcv Kir!.- g.lVl'.l p.lper at the B.bC,)m ['.llmer Re.;idenls n.lY meeting th.lt .;hl)uld be br,)ught tl) the .1ttentil)(1 l)f .111 l)phth.llml) I,)gi.;t.;. She rep,)rted l)n fl)ur in.;t.ll1ces in which p.ltient.; wh,) h.ld been given retwbulb.u bloc!.-s with ~1arc.line (bupiv.lc.line) h.ld e,perienced sudden b,)ut.; l)f apnea and had required intubation and mechanical ventilatil'l1 for 15-20 minutes thereafter. Fl)rtunatelv, in each instance the respiratl) f\' arrest responded to prompt management by a Cl)mpetent anesthesil)logist. .lnd no untow.lrd residu.l were e,perienced in any of these cases. However, Dr. Kir!.- brought the problem to the attention of the ophthalmic community, and further discussion has shown that these were not is,)lated happenstances. Dr. S William Clark, Jr, of Waycross, Georgia, commented that his anesthesiologist was reticent for him to use retrobulbar Marcaine and preferred Xylocaine When asked why he preferred Marcaine, Dr. Clark commented that this was the latest thing, was preferred in all of the big institutions, and gave much longer-acting pain relief after surgerv. Dr. Clark pointed out his anesthesiologist responded that it should be recalled that intravenous Xylocaine is frequently used in intensive care units in the treatment of cardiac arrhythmias. On the other hand, the chances of toxicity with intravascular injections of Marcaine appear to be much greater. Dr. John Costin of Lorain, Ohio, mentioned th.lt recently an instance of respiratory arrest had occurred in his hospital in a patient given a mixture of Marcaine and Xylocaine by retrobulbar injection before ophthalmic surgery In that instance, too, the arrest was properly handled by intubation and ventilation, but the cause for the .lrrest h.ld not been apparent at that time. Dr. James P. Gills subsequently brought to our attention that he had seen several instances of this problem and was preparing a formal report for publication. Dr. Kirk called our attention to .In important paper by Dr. Richard M. Rosenblatt .lnd associates, "Cardiopulmonary arrest after retrobulbar block," which appeared in The American Journal of Ophthalmology (vol. 90, no. 3, pp. 425427, Sept. 1980). Dr. Rosenblatt's patient lost consciousness, became apneic, and experienced asys- September 1981 tole on electrocardiography after a retrobulbar injection of 2 ml of a solution containing a mixture of Marcaine, Carbocaine, and hyaluronidase. The patient remained unconscious for 20 minutes and responded uneventfully to prompt anesthetic management. Dr. Kirk emphasized that in no case in her report was there cardiac arrest-only a cessation of breathing. Dr. Rosenblatt's reported case had many severe medical problems: diabetes mellitus with retinopathy and chronic renal failure, arteriosclerotic heart disease with hypertension and chronic congestive failure, and sideroblastic anemia as well. Obviously, any hypoxia in such a patient could make the patient promptly predisposed to cardiac arrest. There are several points that should be considered in the pathogenesis of these cases. In the patients reported by Dr. Kirk, the amount of retrobulbar solution injected was 6 ml in each case. This large amount had been given on purpose prior to vitrectomy in order to proptose the eye and to have a very long anesthetic action. The material injected was straight 0.75% Marcaine without any added epinephrine or other agents. A #23 gauge flat grind tip retrobulbar needle I i in. long was used in each case. Attempted aspiration before injection failed to bring blood into the syringe. The fi rst thing noted in these cases was a failure of the e,pected proptosis to occur after injection. Shortlv thereafter these p.ltients were noted to shl)w mental disorientation and within 1-2 minutes respi r.ltory .urest occurred. It should be emph.lsized that none ,)f these patients experienced a seizure. In e.lch case, after mechanical ventilation for 15-20 minutes the problem wore off. In Dr. Rosenblatt's C.lse, however, a tllt.l1 of l'l1ly 2 ml of solution was injected. The solution given was m.lde by mixing IO ml of 0.5% bupivacainc HCl (Marc.line), 10 ml of 2% mepiv.1C.line (C.lrboc.linc), .lnd a I-ml .lmpoule of hyaluronid.lsc (150 units). What factors m.lY predispose to this problem? The tot.ll dose of Marc.line given when .l patient is given only b ml is much less than has been given intravenously without any reaction at aiL Therefore, the total dose (or a problem of direct toxicity) probably is an inadequate explanation. Similarly, an intravenous injection via the retrobulbar route probably is not an adequate explanation. Could the 171 Edit\Hi,ll: M,Hc,line solution h.lVc bccn givcn by ,In intra-,lrteri,11 injcction? Onc might think th,lt if ,1 #25 or #27 ncedlc, or cven sm.lller rctrobulb.u ncedlc, h,ld been u~ed it might h,lVe been possible for such ,1 Ill'edle to entcr ,1 sm,,11 ,utery One might even .lspir,lte b,Kk in such ,1 l'ircumst,lIlce ,1Ild not sel' blood ~imply becausc the needle W,IS too slll,,11. However, the likclihood of penetr"ting ,In ,utery so adroitly in f\)ur Llses to thc extent th,lt giving b ml of fluid did (wt cause proptosis would certainly be unlikely. C\)uld the needlc have penetratcd the opti\ nervc or the optic nervc shcath and thc material h.lVe gained immediatc acccss to cerebrospinal fluid or have direct access to the brain? It would seem that thc apparent ease of injcction would preclude direct intraneural injection, but certainly injection into thc optic nerve sheath could have occurred and might not have been noted. The point that Dr. Clark made is the reason this editorial is being written. If the reader is an ophthalmologist in a smaller community and is in the habit of performing eye surgery after local anesthesia which he or she personally administers and does not have an anesthetist or anesthesiologist sitting with each case, and if the surgeon is not peronally adept at endotracheal intubation, it is obvious that if a respiratory arrest occurs under the drapes a catastrophe can result. Therefore, the first thing to emphasize at this point is that if the operator is going to use retrobulbar Marcaine, he or she should be advised of the possibility of respiratory arrest so that immediate and pr~per steps can be taken to handle this. Thus, the ophthalmologist should operate with an anesthetist or anesthesiologist in attendance, or the surgeon should be trained and able to intubate the patient's airway if necessary. It would appear preferable .It this time to use Xylocaine rather than M.Hcaine in such a circumstance, until further inform,ltion is ,It hand. Dr. Clark also made the pertinent point that doing cataract surgery with very sm.ll1 sutures (0a or 10-0) and with proper tcchniquc, his p,ltients simply did not have any particular problem with 172 postoperative pain, and that they usually did not even call for the analgesics he prescribed for postopcrativc pain. In other words, prolonged postopcrativc local anesthesia really was not needed, in his expcriencc, with anterior segment ophthalmic surgcry. Therc are obviously many other questions that remain to be answered. Did the apnea result only from using certain batches of Marcaine? Differences of opinion exist in that regard, but Dr. Kirk found that the problem in the cases she reported did occur with different batches. She pointed out that two different patients had injections from the same bottlc of Marcaine, however, only one had a respiratory arrest. In the final analysis, the following points are suggested' 1. Operate with an anesthetist or anesthesiologist in attendance; otherwise, the surgeon should be trained and able to intubate the patient's airway if necessary when using local retrobulbar Marcaine 2. Do not use a needle smaller than a #23 gauge for the retrobulbar block This should have a dull tip and, in my opinion, preferably should be 1 inch long, not 1~ in. long. 3. The operator should aspirate back on the syringe before injection to ensure that no blood returns into the syringe. Further investigation certainly is warranted into this problem. Mixtures of Marc~ine and Xylocaine should probably be avoided at this time u~til more information is gathered. The most encouraging point in the entire picture to date IS that anesthesia help has been superb in every case of which I have been informed so that no fatality has occurred. However, being forewarned IS torearmed. We would like t\) he.u \)f ,lllY further l)r similar experiences noted by l)thers 5\) that the magnitude of the problem c.ln be ml)re c.uefully evaluated. J. Lawton Smith, M.D. [ournal of Clinical Neuro-ophthalmology [CLcataractsurgery] |