Anesthetic Impacts on the Oculocardiac Reflex: Evidence from a Large, Observational Study
Authors Arnold RW, Jansen S, Seelig JC, Glasionov M, Biggs RE, Beerle B
Received 7 January 2021
Accepted for publication 9 February 2021
Published 5 March 2021 Volume 2021:15 Pages 973—981
Checked for plagiarism Yes
Review by Single anonymous peer review
Peer reviewer comments 3
Editor who approved publication: Dr Scott Fraser
Robert W Arnold,1 Stephen Jansen,2 Joseph C Seelig,2 Mikhail Glasionov,3 Russell E Biggs,2 Brion Beerle2
1Alaska Children’s EYE & Strabismus, Anchorage, AK, 99508, USA; 2Chugach Anesthesia Group, Anchorage, AK, USA; 3Department of Anesthesia, Alaska Regional Hospital, Anchorage, AK, USA
Correspondence: Robert W Arnold
Alaska Blind Child Discovery, Alaska Children’s EYE & Strabismus, 3500 Latouche #280, Anchorage, AK, 99508, USA
Tel +1 907 561-1917
Fax +1 907 563-5373
Email [email protected]
Background: The oculocardiac reflex (OCR) is a sudden vagal bradycardia that can be elicited by traction on an extraocular muscle. Bradycardia is highly variable from case to case necessitating a large sample size to observe small to moderate impact on OCR. While the surgeon’s tissue manipulation has immediate impact on OCR and individual patients may have some proclivity to OCR, we sought to characterize the impact on OCR by the anesthesiologist.
Methods: From 1992 to 2019, during routine, community outpatient general anesthetic strabismus surgery, oculocardiac reflex was prospectively observed utilizing a uniform 10-second, 200 gram square wave tension on each extraocular muscle. Anesthetic parameters were recorded and analyzed with double-cohort design and non-parametric statistics and correlations. We define %OCR as the maximally tension-altered heart rate and a percent of stable pre-tension heart rate.
Results: The median (IQR) confidence intervals OCR for 2527 initial cases was 89% (67% to 97%) without anticholinergic, and 99% (95% to 100%) in 165 patients with anticholinergic. OCR was 81% (62% to 96%) in 1034 with opioids and to 75% (60% to 95%) in 59 with dexmedetomidine and in 189 with IV dexamethasone to 72% (56% to 92%) There was a significant (p< 0.01 Kruskal–Wallis) impact on OCR by various opioids, muscle relaxants and inhalational agents. Linear regression showed significant inhibitory impact on OCR by increased inhalational agent depth and by lower exhaled CO2.
Conclusion: The anesthesiologist can block OCR with sufficient anticholinergics, deeper inhalational agents and robust ventilation, and can augment OCR with opioids, dexmedetomidine and apparently also with dexamethasone.
Clinical Trials Registry: NCT04353960.
Keywords: oculocardiac reflex, trigeminovagal, strabismus surgery, opioids, dexmedetomidine, dexamethasone, anticholinergics
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