Senn P, Jöhr M, Kaufmann S, Schipper I
Augenklinik, Kantonsspital Luzern.
Klin Monbl Augenheilkd. 1993 Jun;202(6):528-32. doi: 10.1055/s-2008-1045639.
Eye surgery is performed under local anesthesia in more than 90% of the cases. While injecting the local anesthetics a deep sedation is desired. During surgery however the patient should be cooperative, such as to avoid inadvertent movements. We routinely perform local anesthesia (retrobulbar injection and van Lint block) under intravenous anesthesia with propofol (Disoprivan) and ketamine (Ketalar, Ketanest).
To control safety and efficacy of this method a prospective study was performed including 100 consecutive patients. The results were to be compared with an earlier study where 35 Patients received midazolam (Dormicum) and alfentanil (Rapifen) as sedation. The actual protocol included the following points: 1. Personal judgement of the patient. 2. Conditions to perform the retrobulbar injection, 3. Intraoperative conditions and additional sedation, 4. Pulse, blood pressure and blood oxygen concentration, 5. Complications
95% of the patients had a total amnesia of the injection of local anesthetics. Retrobulbar injection is comfortable (96%), but may be difficult in patients with a narrow orbit and exotropia (4%). Intraoperative conditions were noted as good in 97%. Additional sedation during surgery was necessary in 3%. Blood pressure and pulse remained stable. Blood oxygen concentration showed a tendency to sink during intravenous anesthesia. This could be managed easily by additional oxygen via face mask if necessary. Postoperative emesis was noted in 3%. No further ocular complications occurred that might be related to the anesthetic management. In an earlier study including 35 Patients under comparable conditions we used midazolam and alfentanil for sedation. The results were similar. Midazolam and alfentanil were then used in over 2000 operations. Often the patients were deeply sedated and asleep during surgery which meant a potential risk of a sudden awakening and moving the head inadvertently. Occasionally paradoxical reactions occurred after midazolam.
Using propofol and ketamine while performing the local anesthesia the patients are awake but relaxed and cooperative during surgery. This method has now been used routinely in over 1000 cases. It has proved to be clinically safe and efficient. It offers the surgeon good working conditions and is well tolerated by the patients, reducing their preoperative and perioperative anxieties.
超过90%的眼科手术在局部麻醉下进行。在注射局部麻醉剂时，希望达到深度镇静效果。然而在手术过程中，患者应保持合作，以避免意外移动。我们常规在使用丙泊酚（得普利麻）和氯胺酮（凯他敏、凯他那）进行静脉麻醉的情况下实施局部麻醉（球后注射和范林特阻滞）。
为控制该方法的安全性和有效性，进行了一项前瞻性研究，纳入100例连续患者。结果将与一项早期研究进行比较，在早期研究中有35例患者接受咪达唑仑（多美康）和阿芬太尼（瑞芬太尼）作为镇静剂。实际方案包括以下几点：1. 患者的个人判断。2. 进行球后注射的条件。3. 术中情况及额外镇静。4. 脉搏、血压和血氧浓度。5. 并发症。
超过95%的患者对局部麻醉剂注射完全失忆。球后注射舒适的患者占96%，但眼眶狭窄和外斜视患者可能较困难（占4%）。术中情况良好的患者占97%。3%的患者在手术期间需要额外镇静。血压和脉搏保持稳定。静脉麻醉期间血氧浓度有下降趋势。如有必要，可通过面罩额外吸氧轻松处理。3%的患者术后出现呕吐。未发生可能与麻醉管理相关的其他眼部并发症。在一项早期研究中，在类似条件下纳入35例患者，我们使用咪达唑仑和阿芬太尼进行镇静。结果相似。此后，咪达唑仑和阿芬太尼在超过2000例手术中使用。手术期间患者常处于深度镇静和睡眠状态，这意味着存在突然觉醒并意外移动头部的潜在风险。偶尔咪达唑仑后会出现反常反应。
在实施局部麻醉时使用丙泊酚和氯胺酮，患者在手术期间清醒但放松且合作。该方法现已在超过1000例病例中常规使用。已证明其临床安全有效。它为外科医生提供了良好的工作条件，患者耐受性良好，减轻了患者术前和围手术期的焦虑。
