an audit of sub-tenons block for squint surgery in children dr steve gilbert queen margaret hospital...
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An Audit ofAn Audit ofSub-Tenons block for Sub-Tenons block for
Squint Surgery in Squint Surgery in Children Children
Dr Steve GilbertDr Steve GilbertQueen Margaret HospitalQueen Margaret Hospital
DunfermlineDunfermline
Introduction
• An audit of the post operative recovery from squint surgery, with and without sub-tenons block was carried out over four years.
• Three surgeons operated on children, one of whom used sub-tenons laevobupivacaine at the end of the procedure (SS) and two who didn’t (AB & AB)
methods
• Children received a standardised analgesic regime during anaesthesia
• Fentanyl 1μg/kg at induction • Diclofenac 2mg/kg PR at the end of
surgery • Paracetamol 20mg/kg as a loading dose,
post op, followed by 15mg/kg 4 hourly • Ibuprofen 10mg/kg 6h post op if reqd• Oramorph 0.3mg/kg if reqd• After repair of the conjunctiva one of the
surgeons injected 1ml 0.5% laevobupivacaine to the sub tenons space (ST) while the others didn’t (N).
Data collection
• Nurses scored the children’s pain and nausea at hourly intervals
• 0 – none• 1 – mild• 2 – moderate • 3 – severe
Other data collected were;
• Operation• Premed• quality of induction (happy-0,
calm-1, scared-2, crying-3 or hysterical-4)
• analgesic and antiemetic drugs given in theatre and in the ward post op
• times of first drink, food and home readiness.
Results
• Between December 2004 and November 2007
• 88 children between the ages of 1 and 17 • 60 had a sub tenons block (68%) and 28
didn’t (32%) • Average age was 6.6 (N) and 5.2 (ST). • Mean quality of induction, graded 0
(happy) to 4 (hysterical) was 0.68 (N) and 0.72 (ST).
• Average length of data collection 5.5h ST & 5.2h (N)
Operations
• Bilateral medial rectus in 28% (N) and 82% (ST)
• Single eye in 43% (N) and 0.8% (ST) • Re-operation in 7% (N) and 1.5% (ST) • Inferior oblique disinsertion in 11% (N) and
5% (ST)
Pain Scores
• The maximum pain scores were 3 in 2%, 2 in 22% of the ST group and 1 in 40%, while 38% had no pain.
• In the N group maximum pain scores were 3 in 11%, 2 in 41% and 1 in 33%.
• Only 3 children had a score of 0 (11%). • Average pain scores were 0.62 (N) and 0.29
(ST).
Paracetamol & other analgesics
0
2040
6080
100
%
P x 1 P x 2 I O
P (paracetamol) I (ibuprofen) O (oramorph)
ST
N
Summary
• The simple technique of sub-tenons block at the end of paediatric squint surgery leads to significantly less postoperative pain.
• Only one child in the sub-tenons group complained of blurred vision.
• There were no complications of the block.
• There was more nausea & vomiting in the Sub-tenons group. ? Significance – follow up needed
Discussion
• Previous studies have used topical retrobulbar or subconjunctival LA
11,2
• No difference in outcome• Pilot study showed significant effect at 2
hours with lignocaine 2%, but follow up RCT only found benefit at 1h.
• 1. Yeşim A, Necmettin Ü, Handan C, Necile E, Postoperative analgesia in children using preemptive retrobulbar block and local anesthetic infiltration in strabismus surgery. Regional Anesthesia and Pain Medicine;23, p 569-574 , 1998
• 2. Carden, S M Adjunctive intra-operative local anaesthesia in paediatric strabismus surgery: a randomized controlled trial. Australian & New Zealand Journal of Ophthalmology. 26(4):289-97, 1998 Nov
• 3. Sheard R, Mehta J, Barry J et al, Subtenons Lidocaine Injection for• Postoperative Pain Relief After Strabismus Surgery in Children: A
Prospective Randomized Controlled Trial Journal of American Association for Pediatric Ophthalmology and Strabismus;8(4):p 314-17. 2004
Conclusion
•Sub-tenons block is an effective technique
•More research needed – multicentre?