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Anestesia regional en cirugía oftalmológica

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Presentación del tema: "Anestesia regional en cirugía oftalmológica"— Transcripción de la presentación:

1 Anestesia regional en cirugía oftalmológica
Luis enriquez, md. RESIDENTE de anestesiología Universidad del valle

2 Descripción de los procedimientos
Parte I Descripción de los procedimientos

3 Introducción La mayoría de procedimientos son realizados con Anestesia Regional Cirugía de catarata: procedimiento mas frecuente La población en general tiene múltiples comorbilidades Respuesta menos predecible a los medicamentos utilizados Demencia, tos incontrolable, temblor marcado de cabeza, niños: BAG Akinetic block of the eye can be accomplished by injection of local anaesthetic in or around the muscle cone through a needle or by instilling local anaesthetic under the Tenon’s capsule using a blunt cannula Anaesthesia without motor blockade is accom- plished with topical application of local anaesthetic drops or gel and by intracameral injection of preservative-free local anaesthetics

4 Van, M. et al. Sedation and Anesthesia Care for Ophthalmologic Surgery
during Local/Regional Anesthesia. Anesthesiology, V 107, No 3, p

5 Consideraciones varían de acuerdo a la práctica y legislación de cada región
Ayuno? Sedación? Anestesiólogo? Acinesia? Clasificación ASA? Uso de Anticoagulantes?

6 Preparación Valoración Monitorización
Examen ocular: infección, trauma, lesiones Tamaño ocular Sedación leve Evitar dolor : Selección de aguja adecuada Velocidad de infiltración s/ml

7 Selección del bloqueo Se nombran de acuerdo a la estructura del ojo donde se aplica el anestésico local Depende del tipo de cirugía, de patología de base, de destrezas del cirujano, experiencia del anestesiólogo.. RETROBULBAR = INTRACONAL PERIBULBAR = PERICONAL = CARUNCULAR = RIZO SUBTENONIANO = EPIESCLERAL LOCAL TOPICO INTRACAMERAL

8 Características de los bloqueos
Topico Sub-Tenoniano Peribulbar Retrobulbar Dolor 0 / - + / ++ ++/+++ +++ Prevención de dolor quirúrgico -- ++ Acinesia --- + Bloqueo de parpados Sensibilidad visual ++/+ + Representa fuerza o evidencia afirmativa 0 insuficiente evidencia - Evidencia contraria o negativa Van, M. et al. Sedation and Anesthesia Care for Ophthalmologic Surgery during Local/Regional Anesthesia. Anesthesiology, V 107, No 3, p

9 Anatomía aplicada: Corte horizontal
Nouvellon, E. Et al. Regional Anesthesia and Eye Surgery, Anesthesiology 2010; 113:1236 – 42

10 Corte sagital

11 Comparación Peribulbar vs Epiescleral
Fig. 2. (A) Semischematic view of a horizontal section of the orbit. 1 = Common insertion of bulbar conjunctiva and Tenon capsule on the eyeball, near the sclerocorneal limbus; 2 = anterior facial sheath of the eyeball (the Tenon capsule); 3 = sclera; 4 = medial rectus muscle; 5 = episcleral space (sub-Tenon); 6 = posterior facial sheath of the eyeball; 7 = lateral rectus muscle. Note the continuity between the Tenon capsule and the sheaths of the rectus muscles. (B) Same view as A, with figurated spread of a local anesthetic injected into the peribulbar space, with subsequent spread into the muscular cone. Because the space for spreading is the adipose tissue of the orbit, including small septas network, this spread may be incomplete or heterogeneous, thus accounting for imperfect blocks. (C) Same view as A, with figurated spread of a local anesthetic injected into the episcleral (sub-Tenon) space. Note the spreading into the whole episcleral space and into the sheaths of the rectus muscles, thus accounting for good akinesia. Because the episcleral space is adherence-free and septum-free, this spread is more constant, thus accounting for more constant akinesia. Additionally, because the anterior Tenon is not tightly sealed, part of the local anesthetic flows to the lids, accounting for akinesia of the orbicularis muscle. Ophthalmic Blocks at the Medial Canthus Ripart, Jacques M.D., Ph.D.*; Benbabaali, Mohamed M.D.; L’Hermite, Joel M.D.; Vialles, Nathalie M.D.; de La Coussaye, Jean-Emmanuel M.D., Ph.D. Author Information *Centre Hospitalier Universitaire de Nîmes, Nîmes, France. Anesthesiology Issue: Volume 95(6), December 2001, pp Peribulbar Epiescleral Ripart, J. Et al. Ophthalmic Blocks at the Medial Canthus. Anesthesiology 95(6), 2001, pp 1533

12 Accesos para los bloqueos
Superonasal Fig. 1. Site of introducing the needle. 1 = Site of introducing the needle for the technique of Hustead; 2 = caruncle; 3 = semilunaris fold of the conjunctiva; 4 = site of introducing the needle for our technique Ophthalmic Blocks at the Medial Canthus Ripart, Jacques M.D., Ph.D.*; Benbabaali, Mohamed M.D.; L’Hermite, Joel M.D.; Vialles, Nathalie M.D.; de La Coussaye, Jean-Emmanuel M.D., Ph.D. Author Information *Centre Hospitalier Universitaire de Nîmes, Nîmes, France. Anesthesiology Issue: Volume 95(6), December 2001, pp 1. Acceso peribulbar de Hustead via Caruncular Rizzo, L. Peribulbar Anesthesia: A Percutaneous Single Injection Technique with a Small Volume of Anesthetic. Anesth Analg 2005;100:94 –6)

13 Deposito extraconal ★ Desde una punción caruncular
A frontal section through the posterior half of the globe. The open star indicates the fat-filled space at the extreme inferotemporal corner of the orbit. The inferior rectus muscle is located at the junction of the lateral one- third and medial two-thirds of the inferior orbital rim, communicates with the intraconal space between the lateral rectus muscle and inferior rectus muscle, . The neurovascular bundle to the inferior oblique lies just lateral to it. The filled star lies in the medial canthal fat-filled space, another relatively safe entry point for an orbital block This extraconal space is an excellent site for the injection of local anesthetic, as it communicates freely with the intraconal space and is virtually devoid of easily damaged structures if appropriately ap- proached. ✪ Desde una punción inferotemporal Fanning, G. Orbital regional anesthesia. Ophthalmol Clin N Am 19 (2006) 221 – 232

14 Localización del anestésico local: intraconal vs extraconal
Fig. 2. A human cadaver head was injected with blue latex into intraconal or extraconal space (coronal section passing just to the posterior pole of the eyeball). (A) Right orbit injected into the intraconal space via an inferotemporal approach (retrobulbar anesthesia). (B) Left orbit injected into the inferotemporal quadrant of the extraconal space (peribulbar anesthesia). * Approximate injection site: 1, lateral rectus muscle; 2, superior rectus muscle–levator palpebrae superioris muscle complex; 3, medial rectus; 4, muscle inferior rectus muscle; 5, optic nerve. Note the spread of latex from one space to the other, through the supposed intermuscular membrane, resulting in a very similar picture after each injection. Reprinted from Ripart J, Lefrant JY, de La Coussaye JE, Prat-Pradal D, Vivien B, Eledjam JJ: Peribulbar versus retrobulbar anesthesia for ophthalmic surgery: An anatomical comparison of extraconal and intraconal injections. ANESTHESIOLOGY 2001; 94:56–62 Copyright © 2001 Lippincott Williams & Wilkins. Used with permission. Ripart J, et al. Peribulbar versus retrobulbar anesthesia for ophthalmic surgery: An anatomical comparison of extraconal and intraconal injections. Anesthesiology. 2001; 94:56–62

15 Depósito por vía epiescleral
Gray, H. Anatomy of the human body. Philadelphia: Lea & Febiger; 1918 Basic Human Anatomy, O´Rahilly, et al. Online.

16 Bloqueo intraconal: “Gold standard” a principios del S. XX
Inyección de pequeños volúmenes (3 a 5ml) de anestésico en el cono de los rectos Akitson: Introducción de una aguja de 40mm via inferotemporal con mirada hacia superomedial Posibilidad de lesiones del globo ocular, los músculos o los elementos intraconales. A caído en deshuso Nouvellon, et al. Regional Anesthesia and Eye Surgery. Anesthesiology 2010; 113:1236 – 42

17 RETROBULBAR O INTRACONAL
Descripción RETROBULBAR O INTRACONAL Cavidad orbital (cono muscular), detrás del globo An intraconal (retrobulbar) block involves the injection of a local anaesthetic agent into the orbital cavity (muscle cone), behind the globe formed by four recti muscles and the superior and inferior oblique muscles Fanning, G. Orbital regional anesthesia. Ophthalmol Clin N Am 19 (2006) 221 – 232

18 Además… No bloqueo adecuado de estructuras no relacionadas con el cono: Frecuente requerimento de refuerzo superomedial (IV par) Requerimento de bloqueo de Nervio facial (Orbicular de los párpados) Lint: Reborde orbitario O´Brien: Cóndilo mandibular Atkinson: Cigomático Nadbath-Rehman: Entre mastoides y límite posterior de rama mandibular La técnica de van Lint es probablemente la más popular de todas las dirigidas a conseguir la acinesia del orbicular. Consiste en introducir una aguja en el borde orbitario externo inyectando una pequeña cantidad de anestésico para crear un pequeño habón intradérmico. Desde aquí la aguja se dirige a lo largo del borde inferoexterno orbitario inyectando de 2 a 4 ml de anestésico a medida que ésta se retira. Después se hace lo mismo a nivel del reborde orbitario superotemporal. Su principal inconveniente es la producción de edema, por lo que algunos cirujanos prefieren usar el método de O¥Brien (bloqueo del nervio facial a nivel del cóndilo mandibular, por debajo de la apófisis cigomática posterior), el de Atkinson, en el que se anestesian las ramas del facial a su paso por el arco cigomático, o el de Nadbath-Rehman, que actúa sobre el tronco facial principal al inyectar el fármaco en el espacio existente entre el borde anterosuperior de la apófisis mastoides y el límite posterior de la rama mandibular8. Nouvellon, et al. Regional Anesthesia and Eye Surgery. Anesthesiology 2010; 113:1236 – 42 Garralda, L. Et al. Anaesthesia in ophthalmology. Ann Sist San Navarra , Supp. 2

19 Bloqueo Peribulbar Descrito por Davis and Mandel en 1986, desplaza el BRB, múltiples variaciones en técnica Aguja de 1 pulgada, calibre 25 Se pueden administrar 12 mL de solución anestésica administrados desde diferentes puntos de acceso al espacio peribulbar Aumento de la PIO, efectividad dependiente de volumen

20 Descripción BPB Doble punción
Se efec- túa una doble punción, la primera en el mismo punto que la retrobulbar pero sin atravesar el septum inter- muscular (Figuras 1 y 2) con una profundidad nunca superior a los 25 mm y se depositan 4-6 ml de anesté- sico y la segunda inyección se realiza a través del pár- pado superior 2 mm por dentro y debajo de la escota- dura supraorbitaria siguiendo el plano sagital del techo de la órbita, sin sobrepasar los 25 mm y depositando 2-3 ml de anestésico Doble punción Inferotemporal sin atravesar el septum muscular Superonasal : 2mm por dentro y debajo de escotadura supraorbitaria

21 Caruncular Aguja 25 Se inserta en el túnel
Dirección hacia pared medial Al tocar la pared, se retira 1 mm Se redirecciona para ingresar paralela a 25-gauge, 1-in needle (some practitioners use a 30-gauge 0.5-in needle) is inserted into the tunnel that lies between the caruncle and the medial canthus The needle tip is directed at first toward the medial wall redirected so that it can be inserted into the orbit parallel to the medial wall and the floor, The bevel of the needle during insertion should face the orbital wall to keep the tip of the needle away from the wall

22 Elevación de la Presión intraocular
Murgatroyd, H. et al. Intraocular pressure. Continuing Education in Anaesthesia, Critical Care & Pain, 8 (3) 2009

23 Balón de Honan Reduce PIO asociada a bloqueo de orbita
Usarlo 20min a 20mmHg de presión previo a procedimiento Controversia en su uso Method of use • Tape the eyelids closed to avoid corneal abrasion. • Apply a cotton eye pad or 4 x 4 gauze over the eye • Apply the head strap around the back of the head • Position the balloon over the cotton pad on the eye to be operated eye and secure the headband firmly but not tight • Inflate the balloon to the desired pressure. Some use 30-mm mercury. A pressure of 20-mm mercury is satisfactory. • Keep the balloon on the eye 20 minutes or longer • The balloon may be removed to apply eye drops and reapplied • Remove the balloon in the OR just before the surgical prep

24 Bloqueo subtenoniano Se retrae el parpado inferior
Se pinza la conjuntiva y la capsula subtenoniana en el cuadrante inferonasal Paciente mirando arriba y afuera Se hace una incisión pequeña Se inserta cánula en la curvatura del GO Se coloca 4-5 ml de AL The lower eyelid is retracted or a speculum used. Using no touch technique, the conjunctiva and Tenon’s capsule are gripped with a nontoothed forceps 5–10mm away from the limbus usually in the inferonasal quadrant while the patient is asked to look upwards and outwards.

25 Parte II Complicaciones

26 Introducción Complicaciones rara pero con serias consecuencias
Conocerlas para evitarlas Conocer el manejo Complicaciones frecuentemente reportadas por oftalmólogos Complications are rare but can have serious consequences. A prior knowledge of the possible complications of the procedure, together with a thorough knowledge of orbital anatomy, will lead the anesthesiologist to exert care to avoid them.8 The ability to recognize the complication and provide suitable therapy promptly can be life-saving and sight-saving. Unfortunately, most anesthesiologists are unaware of these complications because the majority are documented only in the ophthalmologic literature.

27 NYSORA, online.

28 Clasificación AMENAZAN LA VIDA AMENAZAN LA VISION Anestesia Central
Convulsiones Bloqueo de nervios craneales Hemorragia retrobulbar Perforación ocular Oclusión vascular retina Miotoxicidad ocular Trauma directo en el nervio Lesión corneal A. Life-Threatening Brain stem anesthesia Seizures Cranial nerve block B. Sight-Threatening Retrobulbar, peribulbar hemorrhage Ocular penetration/perforation Retinal vascular occlusion Ocular myotoxicity Direct nerve trauma Corneal injury

29 Hemorraga Retro y Peribulbar
Incidencia 1 a 3% Desde leve equímosis hasta proptosis, equimosis conjuntival y palpebral y aumento PIO Perdida de la visión Aumento de la PIO Alteración de la circulación Atrofia de NO The reported incidence of hemorrhage associated with ophthalmologic blocks varies from 1% to 3%.34 It varies in severity, from mild ecchymosis to major hemorrhage with proptosis, conjunctival, and palpebral ecchymosis and elevated IOP. Major hemorrhage occurs less frequently with the peribulbar technique and rarely results in elevated IOP. Retrobulbar hemorrhage has been associated with visual loss, which may be related to the increased orbital pressure and resultant impaired circulation in the ophthalmic artery,35 or compromise of the small nutrient blood vessels in the optic nerve causing late optic atrophy and visual loss.36

30 Manejo Según riesgo de suplencia vascular y severidad de hemorragia
Medir PIO prontamente Presión digital intermitente Reducir PIO (manitol) Cantotomía lateral Paracentesis de cámara anterior Decompresión orbitaria The treatment is based on the severity of the hemorrhage and the risk to the blood supply of the eye. Intraocular pressure must be measured promptly, as treatment will be necessary in the event of a marked elevation. Immediate intermittent digital pressure at the bedside is beneficial in reducing IOP and reducing further hemorrhage. Intravenous (IV) mannitol may be used to lower IOP but the onset of action is slow. Lateral canthotomy, incision of the conjunctiva, and Tenon’s capsule in the appropriate quadrant, can promptly reduce the orbital pressure. Anterior chamber paracentesis may be necessary, but this procedure carries the risk of intraocular hemorrhage.37 If the pressure is not reduced by these measures, orbital decompression through a transantral approach38 or through the medial orbital floor has been advocated.39

31 Perforación Incidencia 1:1000 a 1:12000 GRUPOS DE RIESGO
Miopes (mayor 30 v) Esclera delgada Estafilomas Enoftalmos Buckle escleral The reported incidence of ocular perforation during placement of ophthalmologic blocks varies from 1:1,00040 to 1:12, Patients at risk include myopics, who usually have a greater antero-posterior diameter and thinner sclera. The risk of perforation is 30 times greater in the myopic patient than in the normal population Patients with enophthalmos or posterior and inferior staphylomas are another group who are at increased risk for perforation. Patients who have undergone a previous scleral buckle procedure are at risk for this complication due to increased axial length as a result of the surgery.42–

32 Relación globo órbita Fanning, G. Orbital regional anesthesia. Ophthalmol Clin N Am 19 (2006) 221 – 232

33 Relacion miopia y longitud axial
n=1325 ojos Fig. 6. Axial length versus spherical equivalent in 1325 eyes. Patients who are highly myopic (and have eyeglass prescriptions with large negative spherical equivalents), tend to have very long eyes. Axial length is plotted against spherical equivalent. The bars represent two standard deviations from the averages. When performing a block on a patient who has not had an their axial length measured, it is useful to look at the spherical equivalent in the eyeglass prescription to estimate the length of the eye. (Gary L. Fanning, MD, unpublished data, 2000.) Fanning, G. Orbital regional anesthesia. Ophthalmol Clin N Am 19 (2006) 221 – 232

34 Orbitas pequeñas: 20% 1.5 pulgadas = 3.81 cm Fig. 7. Orbital length in 120 skulls. Orbital length is plotted against the percentage of orbits that have specific lengths. About 20% of orbits are short enough that a 1.5-in needle can reach within 7mm of the optic canal where structures are tightly packed. (Adapted from Katsev DA, Drews RC, Rose BT. An anatomical study of retrobulbar needle path length. Ophthalmology 1989; 96:1221–4; with permission.) Con agujas de 1.5 pulgadas se puede alcanzar dentro de 7mm el canal óptico Fanning, G. Orbital regional anesthesia. Ophthalmol Clin N Am 19 (2006) 221 – 232

35 Clínica Complicación que puede ser detectada postqx
Dolor y hemorragia vítrea 100% Desprendimiento retina 55% Hipotonía 30% Aumento de PIO 10% Perforation is associated with pain, and vitreous hemorrhage will be present in all cases. Retinal detachment (55%) and hypotony (30%) or sudden increase in IOP (10%) has also been reported. Pain associated with this complication may be obscured by the use of the newer potent IV drugs such as remifentanil and propofol, which are used for sedation. In some instances, the complication may not be recognized until the time of the postoperative examination. In 50% of cases in the literature, the operating surgeon was unaware of the perforation at the time of surgery,45 and only detected the problem postoperatively. Complicación que puede ser detectada postqx 50% de qx no reconocen perforación intraqx

36 Remoción hemorragia vítrea, retinopexia laser o crioterapia
Pronóstico Evaluación pronta por retinólogo Resultado según localización y presencia de DR NO DR Remoción hemorragia vítrea, retinopexia laser o crioterapia Incidencia futuro DR 11% DR Bucle escleral, vitrectomia, gas intravítreo o taponamiento con silicón If ocular perforation is suspected, prompt evaluation by a retinal specialist is absolutely necessary. The final outcome of the eye is dependent on the location of the perforation and the presence or absence of a retinal detachment. If no retinal detachment is present, removal of vitreous hemorrhage, in conjunction with laser retinopexy or transceral cryotherapy of the perforation sites, is recommended. In these cases, the incidence of future detachment is only 11%. If treated with photocoagulation or cryotherapy, 56% of patients may have no significant impairment of visual activity. If retinal detachment is present, scleral buckle, vitrectomy, and intravitreal gas or silicone oil tamponade is performed. In these instances, the long-term reattachment rate is reduced to 64% due to proliferative vitreous retinopathy, and despite surgical repair visual acuity will be decreased.

37 Mezclas de anestésico local
Altas concentraciones de AL son miotoxicas Evitar inyecciones directas al musculo Hialuronidasa: Velocidad de inicio Calidad del bloqueo Rápida difusión: ayuda a disminuir PIO Epinefrina: a concentraciones >1: mil Contraindicado en problemas vasculares de retina The higher concentrations of local anesthetics are known to be significantly myo- toxic in laboratory investigations [7,8] and may be so in selected patients [22]. They will certainly be toxic if injected directly into a muscle. Hyaluronidase does slightly speed the on- set of block and perhaps improves the quality of the:

38 Anestesia del tallo cerebral
Síndrome de apnea retrobulbar Amenaza vida Incidencia 0,79% Mayor con bloqueo retrobulbar Síntomas: Nauseas –vómito Disfagia Amaurosis contralateral Parálisis facial Afasia Hemiplejia Bradicardia Paro cardio respiratorio This complication has also been referred to as “retrobulbar apnea syndrome”, and it is potentially life-threatening. It has been reported by several authors who used various local anesthetic drugs.8–10 The frequency noted by Wittpenn et al.,8 at the Wilmer Eye Institute, where they evaluated 3,123 patients who had received ophthalmologic blocks, was 0.79%. This complication is more likely to occur during the placement of retrobulbar block than peribulbar injection. The symptoms vary from focal signs such as nausea, vomiting, dysphagia, contralateral amaurosis, facial paralysis, aphasia and hemiplegia; to bradycardia and cardiac and respiratory arrest

39 Características Inicio gradual 2 a 8 min Duración 5 a 55 min
Resuelve sin secuelas Inyección AL vaina nervio Entrada de AL al espacio subaracnoideo Asociado a resistencia en la aplicación The onset is gradual, ranging from 2 to 8 minutes, and the duration ranges from 5 to 55 minutes. It usually resolves without any long-term sequelae if appropriate supportive measures are instituted. The mechanism is felt to be the entry of the local anesthetic into the subarachnoid space as a result of direct injection into the optic nerve sheath. Subsequent spread centrally to the cistern in the middle cranial fossa results in brain stem anesthesia.15 By injecting cadavers with methylene blue solution and using contrast radiography inpatients, it has been demonstrated that the optic nerve sheath is composed of meninges that are continuous with those of the neurocranium. The outer sheath consists of dura mater, while the inner sheath is composed of arachnoid and pia mater.*16–19 Increased resistance to injection has been described in association with this complication and following respiratory arrest local anesthetic has been obtained by lumbar puncture.20

40 Factores asociados Posición ojo: Atkinson Longitud de la aguja
1 ½ pulgada: 11% chance RECOMENDACIÓN Ojos en posición neutra Aguja 1 ¼ pulgada Cadaver experiments have shown that the position of the eye during the injection is a contributing factor and the upward and inward gaze described by Atkinson is no longer advocated. Instead, the neutral position, with the gaze directed straight ahead, is recommended, because this position will move the nerve away from the needle being inserted into the muscle cone when performing the retrobulbar block.22 Furthermore, a study of 60 skulls found that the length of the needle is also a factor. The distance from the inferolateral orbital rim to the optic foramen is 42 to 54 mm. The standard Atkinson needle is 35 mm (11⁄2 inches) and has an 11% chance of perforating the optic nerve.23 Based on this finding, use of shorter needles, such as the 31 mm (11⁄4 inches) in length, is advisable so as to avoid this complication. If resistance to injection of a small volume (0.1 mL) of local anesthetic is encountered while performing a retrobulbar block, the needle should be withdrawn a 1⁄4 inch before completing the injection

41 Convulsiones Inyección intravascular de AL
Depresión centros inhibitorios amígdala Flujo retrógrado arterial Producido aun con pequeñas dosis de AL Grand mal seizures following inadvertent intravascular injection of local anesthetic are the result of the selective depression of inhibitory centers in the amygdala.24 Retrograde flow in the arterial system allows direct access to the cerebral circulation,25 and, under those circumstances, accidental intra-arterial injection of a very small dose of local anesthetic can cause seizures.

42 Sitio de punción aspiración AREAS SEGURAS: -Inferotemporal -Supranasal
RIESGOS -Medionasal: Art supraorbitaria, V. orbitaria sup -Lesión art. Palpebrales The two safest areas are at the inferotemporal and superonasal quadrants, which correspond to the two most common injection sites for placement of ophthalmologic blocks. It has been suggested that the superior nasal angle be avoided since inadvertent injection of local anesthetic into the superior oblique muscle tendon may result in Brown’s syndrome, or inability to elevate the eye in the adducted position.27 Injection in the adipose tissue areas at the midsuperior location of the orbit may result in injury to the supraorbital artery or the superior ophthalmic and the superior orbital veins. At the inferotemporal and superonasal quadrants, the palpebral arteries may be injured resulting in lid hematomas. The medial collateral vein may be damaged by injection at the inferonasal quadrant. Careful aspiration and use of a small test dose before injection of the total volume of local anesthetic will prevent this complication aspiración

43 Oclusión vascular de la retina
Compromiso de Art central retina, mixtos Lesión por aguja Compresión por hemorragia Inyección dentro del nervio de AL Oclusión venosa Hemorragia preretinal macular Oclusión arteria EPINEFRINA It may involve the central retinal artery or both the artery and vein. In some cases, there may be predisposing vascular or hematological disease.50,51 The artery may be injured by the needle as it runs inferior to the nerve before entering the nerve, or the artery may be compressed by hemorrhage within the optic nerve sheath.52 Injection of local anesthetic into the optic nerve sheath can result in central retinal vein occlusion initially and preretinal hemorrhage over the macula, followed by retinal artery occlusion from the pressure as increasing volume is injected.5

44 Diagnóstico Fondo de ojo TAC (N. óptico dilatado) Dx despúes de qx
Perdida de visión Retinal examination with an indirect ophthalmoscope is recommended if vascular injury is suspected. If the retinal vessels are not patent, a computed axial tomographic (CAT) scan of the optic nerve may reveal a dilated nerve sheath due to the hemorrhage, which will have to be surgically decompressed.50 Because, in most cases, the vascular occlusion is often detected a few days after the surgery, the visual loss may be permanent.

45 Lesión directa del NO Inyección intraneural de AL Ceguera
Asociado método Atkinson No inyectar ante resistencia Compromiso ganglio ciliar o fibras parasimpáticas Pupila dilatada Intraneural injection of local anesthetic resulting in blindness has been noted with retrobulbar blocks performed using the Atkinson method.54 For this reason, it is now recommended that the block be performed with the eye positioned in the neutral gaze. This complication can also be avoided by redirecting the needle if any resistance is encountered. Injury to the ciliary ganglion or parasympathetic fibers may occur during retrobulbar block placement and may result in a permanently dilated, nonreactive pupil.

46 Miotoxicidad Incidencia 1 a 13% Igual en retro o peribulbar
FACTORES ASOCIADOS: Espéculo Desinserción elevador párpado Injuria rectos Miotoxicidad AL Inicio en 24 A 48 H, 25% es permanente Ptosis following ocular surgery has been widely reported. 56–59 The incidence ranges from 1% to 13.5%, and it is seen with retrobulbar and peribulbar blocks with equal frequency.60 Ptosis has also been reported following general anesthesia. Multiple factors have been implicated, including traction from the lid speculum or bridle suture, disinsertion of the levator aponeurosis, injury to the rectus muscle, and myotoxicity of the local anesthetic. It has been suggested that the addition of hyaluronidase to the local anesthetic solution may protect the extraocular muscles from the toxicity of the local anesthetic by facilitating diffusion of the drug.60 Ptosis is common within 24 to 48 hours after surgery; however, 25% of patients with postoperative ptosis may have permanent damage

47 Miotoxicidad Regeneración fibras en 1 ss
Retorno a lo normal 1 a 2 meses Severidad según localización, volumen, concentración, injuria muscular, inyección IM The ocular myotoxic effect of local anesthetics has been studied in rats and rhesus monkeys.61,62 The local anesthetics cause severe damage of muscle fibers within minutes of contact, with regeneration starting at the end of 1 week and return to normal in 1 to 2 months. If the initial lesion is associated with ischemia, as seen with mepivacaine or lidocaine with epinephrine; regeneration is delayed since new blood vessels must grow into the area. This is not the case with bupivacaine, where a functional capillary bed is maintained. The severity of the deficit is dependent on several factors, such as location of the injection, volume and concentration of the local anesthetic, injury to the muscle, and possible intramuscular injection. To decrease the possibility of this complication, it has been recommended that the peribulbar injection be made medially or laterally to the vertical recti muscles and that the smallest volume and lowest concentration necessary be used. Repeated injections should be avoided

48 Lesión corneal Daño por exposición Cubrir ojo después de procedimiento
To prevent damage to the anesthetized cornea because of exposure, the eyelids should be kept closed and covered following the placement of the ophthalmologic block. When closing the eye, it is important to make sure that the lids are completely approximated to prevent drying of the cornea due to the absence of blinking and suppression of lacrimal gland function

49 Reflejo oculocardiaco

50 GRACIAS


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