The Risk of General Anesthesia in the First 3 Years of Life
Rudolph S. Wagner, MD
Journal of Pediatric Ophthalmology and Strabismus. 2019;56(6):348
When I am asked about the risks for a child undergoing ophthalmic surgery, I describe the possible complications and unexpected outcomes. I also tell the caregivers that the risk of general anesthesia may be greater than the surgical risk, particularly in infants and young children. This includes both acute intraoperative events and long-term neurodevelopmental effects as described in Cavuoto et al.’s article in this issue. The authors remind us that in 2016 the U.S. Food and Drug Administration issued a warning that general anesthesia may affect brain development in children. This warning was based on the accumulating data from animal and human studies. These are summarized nicely by the authors. It is noteworthy that procedures lasting more than 3 hours and multiple procedures requiring separate anesthesia exposures are particularly concerning. Fortunately, most of our procedures last less than 3 hours, but many conditions that we treat require reoperations or multiple examinations under anesthesia. Therefore, our patients are at risk.
Animal studies have demonstrated higher rates of dysregulated neuronal apoptosis in animals exposed to some of the common agents used in general anesthesia procedures such as sevoflurane. There are conflicting results in laboratory studies on the neurotoxicity of anesthetic agents in humans. Prospective human studies have not demonstrated intelligence quotient differences in children exposed to anesthetic agents versus controls. However, the Mayo Safety in Kids study suggests a possible modest negative impact in executive functions such as verbal coding and reading skills in children with multiple anesthetic exposures prior to 3 years of age.
Currently, adjuvant therapies to mitigate the effects of anesthetic agents are being investigated. As ophthalmic surgeons, we should strive to minimize our operating time with skilled efficient surgery and perhaps look for alternatives to examinations under general anesthesia for our youngest patients.
Strabismus Surgery Infection Prophylaxis and Timing of First Postoperative Visit
Caroline N. DeBenedictis, MD; Shaden H. Yassin, MD; Kammi Gunton, MD; Leonard B. Nelson, MD; Benjamin E. Leiby, PhD; Sarah E. Hegarty, MPhil; Bruce Schnall, MD
Journal of Pediatric Ophthalmology and Strabismus. 2019;56(6):354-359
PURPOSE:
To characterize the practice patterns of pediatric ophthalmologists regarding infection prophylaxis for strabismus surgery and timing of the first postoperative visit.
METHODS:
A ten-question multiple-choice, close-ended questionnaire was e-mailed to members of the American Association for Pediatric Ophthalmology and Strabismus listserv. Survey responses were summarized using frequencies and percentages. Univariable tests of association between prophylactic measures and surgeons reporting a prior episode of postoperative cellulitis or endophthalmitis were performed.
RESULTS:
Three hundred eighty pediatric ophthalmologists completed the survey. Most ophthalmologists instill 5% povidone-iodine solution during surgical preparation (88.4%), use topical antibiotics with or without steroids at the conclusion of surgery (90%), and prescribe oral or topical antibiotics postoperatively (85.5%). Eighty-five percent of strabismus surgeons routinely see patients for the first postoperative visit within the first week, although there is no consensus as to which day is preferred. Responders previously reporting experience with a postoperative infection were more likely to use intraoperative intravenous antibiotics (P = .002) and Tegaderm tape (3M, St. Paul, MN) or other adhesive drape to isolate the eyelids/eyelashes (P = .047).
CONCLUSIONS:
A common practice pattern appears to exist regarding the use of 5% povidone-iodine solution in surgical preparation, application of topical antibiotics at the end of surgery, and a postoperative regimen of topical antibiotics/steroids. There is no prevailing practice pattern regarding the timing of the first postoperative visit. Previous experience with postoperative cellulitis or endophthalmitis may lead to the adoption of more formidable infection prophylaxis measures such as intravenous antibiotics prior to surgery.
Instillation of 5% Povidone-Iodine Ophthalmic Drops Decreases the Respiratory Rate in Children Undergoing Strabismus Surgery: A Randomized Controlled Trial
Michelle S. Rovner, MD; Bethany Jacobs Wolf, PhD; Melanie Rubin, BS; Alexandra Ritter, BS; Christopher L. Heine, MD; Tracy E. Wester, MD; Cory M. Furse, MD, MPH, FAAP
Journal of Pediatric Ophthalmology and Strabismus. 2019;56(6):378-382
PURPOSE:
To investigate the effects of topical application of ophthalmic 5% povidone-iodine eye drops, which has been reported to cause apnea in spontaneously breathing children during general anesthesia.
METHODS:
The authors conducted a randomized, controlled, single-blinded study comparing the effect of balanced salt solution eye drops and povidone-iodine eye drops on respiration in spontaneously breathing children during general anesthesia with sevoflurane via a laryngeal mask airway. Fifty patients received balanced salt solution eye drops and 50 patients received 5% povidone-iodine eye drops.
RESULTS:
None of the control patients had a significant change in respiration. Thirty of the 50 (60%) povidone-iodine patients had a slowing of respiration within the first 6 breaths after eye drop instillation (P < .001). The median time of respiratory pause in those 30 patients was 18.5 seconds (range: 4.36 to 96.2 seconds). Among the povidone-iodine patients, children with a history of a prior tonsillectomy and adenoidectomy and/or bilateral myringotomy had a 7.2 times greater chance of experiencing a change in respiration after instillation of the povidone-iodine eye drops.
CONCLUSIONS:
Topical application of 5% povidone-iodine eye drops causes a slowing and pause in spontaneous ventilation in a majority of children prior to strabismus surgery. This may represent activation of the diving reflex.