12/4/22, 1:04 PM Efficacy and safety of dexmedetomidine as an additive to local anesthetics in peribulbar block for cataract surgery - PMC

Anesth Essays Res. 2013 Jan-Apr; 7(1): 39–43. PMCID: PMC4173478

doi: 10.4103/0259-1162.113987: 10.4103/0259-1162.113987 PMID: 25885718

Efficacy and safety of dexmedetomidine as an additive to local anesthetics in

peribulbar block for cataract surgery
Shivakumar M. Channabasappa, Vijaya R. Shetty,1 Shruthi K. Dharmappa,2 and Jahanabi Sarma

Department of Anaesthesiology, KVG Medical College and Hospital, Karnataka, India

1
Department of Ophthalmology, KVG Medical College and Hospital, Karnataka, India
2
Department of Oral Pathology, Sharavathi Dental College, Karnataka, India
Correspondence author: Dr. Shivakumar M. Channabasappa, Department of Anaesthesiology, SSS Mansion, 3rd
Cross, Basaveshwara Nagar, Shimoga, Karnataka, India. E-mail: drshivakumar.m.c@gmail.com

Copyright : © Anesthesia: Essays and Researches

This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-
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Abstract

Background and Objectives:

We evaluated the effect of adding dexmedetomidine to lidocaine and bupivacaine for peribul‐
bar block in two different doses. The primary endpoints were the onset and duration of
corneal anesthesia, globe akinesia, and duration of analgesia.

Materials and Methods:

A randomized controlled clinical trial was conducted on 90 ASA I-II patients scheduled for elec‐
tive cataract surgery under peribulbar anesthesia. Patients were randomly allocated to one of
three groups of 30 each; group C (control) received 3 ml of 2% lidocaine with 3 ml of 0.5%
bupivacaine; group D50 received 3 ml of 2% lidocaine with 3 ml of 0.5% bupivacaine and 50 ug
of dexmedetomidine; and group D25 received 3 ml of 2% lidocaine with 3 ml of 0.5% bupiva‐
caine and 25 μg of dexmedetomidine.

Results:

The onset of corneal anesthesia and globe akinesia was significantly shorter in group D50 (P <
0.001) as compared to group C; however, in Group D25 onset of corneal anesthesia was signifi‐
cantly faster, but not onset of globe akinesia (P = 0.45). The duration of corneal anesthesia and
globe akinesia was significantly longer (P < 0.001) in both Group D50 and Group D25 in com‐

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parison to Group C. Decrease in IOP was observed in both group D50 and group D25 at 5 min‐
utes and 10 minutes following peribulbar block which was significant (P < 0.05) compared to
group C.

Conclusion:

Addition of dexmedetomidine to lidocaine and bupivacaine in peribulbar block shortens the

onset time and prolongs the duration of the block and postoperative analgesia. It also provides
sedation which enables full cooperation and potentially better operating conditions.

Keywords: Cataract surgery, dexmedetomidine, peribulbar block

INTRODUCTION

Peribulbar block is commonly used for cataract surgery in adults,[1] most commonly local
anesthetics were injected into peribulbar space, but using only local anesthetics for peribulbar
anesthesia is associated with delayed onset of globe akinesia and corneal anesthesia,[2] short
duration of analgesia and frequent need of block supplementation.[3] To decrease the time of
onset of action and increase the duration of analgesia, many additives[4,5,6,7,8] such as cloni‐
dine, hyluronidase, sodium bicarbonate and adrenaline were added to local anesthetics with
limited success.

Dexmedetomidine is centrally acting highly specific α2-agonist commonly used as sedative, pre‐
emptive analgesic[9] and to maintain stable hemodynamics in laparoscopic surgeries.[10] It
also has been used has additives to local anesthetics in peripheral nerve block, brachial plexus
block[11] and subarachnoid anesthesia, but none of the studies has been shown the effect of
dexmedetomidine on peribulbar block for cataract surgery.

We therefore conducted a prospective, randomized control, double-blinded study to evaluate

efficacy of dexmedetomidine on peribulbar anesthesia performed with either mixture of 0.5%
bupivacaine and 2% lidocaine or 0.5% bupivacaine and 2% lidocaine with different doses of
dexmedetomidine for cataract surgery.

MATERIALS AND METHODS

After local ethical committee approval and obtaining informed consent from patients, 90
American Society of Anaesthesiology (ASA) physical status I or II patients of either sex, aged
18-80 years scheduled for elective cataract surgeries under peribulbar block were prospec‐
tively enrolled in this study.

Patients with history of hypersensitivity to study drugs, significant cardiovascular disease (sec‐
ond [Mobitz II type] or third degree heart block, congestive heart failure, chronic heart failure
(New York heart association [NYHA] III-IV), symptomatic coronary artery disease), uncon‐
trolled hypertension, (body mass index [BMI]>35), uncontrolled diabetes (blood sugar >250
recorded in last 30 days or HbA1c >7.5%), chronic clonidine therapy, hepatic impairment
(CHILD B or higher), renal impairment, ongoing drug or alcohol abuse, coagulopathy and

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pregnancy were excluded from study. Details of the anesthetic technique and study protocol
were explained to the patients at the preoperative visit. Patients were not premedicated. No
topical anesthetic or IV sedative medications were used before or during the block.

Using a computer-generated list, the subjects were randomly and evenly assigned into three
groups (n_30): C, D50, and D25. All healthcare personnel providing direct patient care, and the
subjects were blinded to the “study drugs” injected. All medications were prepared by anesthe‐
siologists not participating in the study except for preparing the drugs. They received and kept
the computer-generated table of random numbers according to which random group assign‐
ment was performed. According to the randomizing table, the drug to be injected in the
peribulbar block was prepared in 10-ml syringes to equal volume of 6.5 ml in all three groups
and labelled indicating only the serial number of the patient.

Standard monitoring consisting of intermittent noninvasive blood pressure, continuous elec‐

trocardiogram, heart rate, and pulse oximetry by Mindray Beneview T8 (Mindray Medical
International Limited) were recorded. Hemodynamic variables were recorded every 5 min un‐
til completion of surgery.

The peribulbar block was performed by one of two authors (VRS and SMC) with substantial
expertise in regional anesthesia for ophthalmic surgery.

Group-C patients received peribulbar anesthesia using a mixture of 3 ml of 2% lidocaine, 3

ml of 0.5% bupivacaine and 0.5 ml of normal saline.
Group D50 patients received peribulbar anesthesia using a mixture of 3 ml of 2% lidocaine,
3 ml of 0.5% bupivacaine and 50 μg of dexmedetomidine (50 μg in 0.5-ml saline).
Group D25 patients received peribulbar anesthesia using a mixture of 3 ml of 2% lidocaine,
3 ml of 0.5% bupivacaine and 25 μg of dexmedetomidine (25 μg in 0.5 ml saline). Each
patient received total volume of 6.5 ml.

Peribulbar block was performed using 26-G, 13-mm short bevelled needle; the needle was in‐
serted through the conjunctiva as far laterally as possible in the inferotemporal quadrant. Once
the needle is under the globe, it was directed along the orbital floor, passing the globe's equa‐
tor to a depth controlled by observing the needle/hub junction reach the plane of the iris. 3.5
ml of “study drug” was injected slowly; in the same way other 3 ml of “study drug” was injected
at 2 mm medial and inferior to supra-orbital notch.[12] Gentle ocular massage was applied to
eyeball to promote the spread of local anesthetic and to decrease the intraocular pressure
(IOP), at the same time IOP was measured using indentation tonometry at 5 min before injec‐
tion and 1, 5 and 10 minutes after injection. Corneal sensation was evaluated using cotton wick
at every 30 seconds till the onset of anesthesia and every 15 minutes till recovery. Ocular
movement was evaluated at 2-minute interval in all four directions using 3-point scale. 0-com‐
plete akinesia, 1-limited movement, 2- normal movement.[4] Time for adequate conditions to
start the surgery was defined as presence of corneal anesthesia together with the total ocular
movement score ≤1 and eyelid squeezing score of 0. If a block is inadequate for more than 10
min after injection of “study drug”, additional injection with 2 ml of lidocaine 2% injected
inferotemporally.

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Sedation levels were assessed with modified Ramsay sedation scale (1-Anxious and agitated or
restless or both, 2-Cooperative, oriented, and tranquil, 3-Responds to commands only, 4-Brisk
response to light glabellar tap or loud auditory stimulus, 5-No response to light glabellar tap
or loud auditory stimulus) at every 10 minutes during surgery and every 30 minutes in first 2
hours.

Duration sensory and motor block was assessed by onset of pain and recovery of eyeball
movement respectively. At the same time on the first postoperative day, the following variables
were also recorded: Degree of pain (by using a 5-points verbal rating score: 0-no pain, 1-mild
pain, 2-moderate pain, 3-severe pain, 4-unbearable pain). The pain was assessed at the end of
surgery and every 60 mins up to 2 h and then at 6 h and 24 h. A tablet of paracetamol 500 mg
was given if a verbal rating scale score was ≥2. The time of first request for analgesic and total
analgesic requirement in 24 hrs was recorded.

Statistical analysis

To calculate the required study size, we took into account the results of a previous pilot study
with 15 patients per group (unpublished observations). Accepting a one-tailed α-error of 5%,
a β error of 5% and power of 90%.[13] Based on these calculations, the required study size
was 30 patients per group.

Statistical analysis was performed using the program GraphPad prism software package v. 5
(GraphPad Inc., CA, USA). Numerical variables were presented as mean and standard deviation
(SD) and categorical variables were presented as frequency (%). One-way ANOVA was used for
between-group comparisons of numerical variables, if its assumptions were fulfilled, otherwise
for nonparametric, the Kruskal–Wallis test was used. Tukey's HSD test or the Mann–Whitney
test was used, whenever appropriate, as post-hoc tests. χ2 test was used for between-group
comparisons between categorical variables. A P value of ≤0.05 was considered statistically
significant.

RESULTS

Patient characteristics and duration of surgery were similar in all three groups [Table 1]. No
differences in baseline hemodynamic variables, IOP and peripheral SpO2 were reported be‐
tween the three groups (data not presented). The incidence of successful block was also com‐
parable in all the groups. In Group D50, intraoperative mean heart rate was found to be lower
up to 60th min (P = 0. 032) and arterial pressure lower up to 30th min (P = 0.049). One dose of
atropine (0.3 mg) was needed in six patients in Group D50. However, there was no need to ad‐
minister ephedrine to any patients.

The onset of corneal anesthesia and globe akinesia was significantly shorter in group D50 (P <
0.001) as compared to group C but in Group D25 onset of corneal anesthesia was significantly
faster but not globe akinesia (P = 0.45) as compared to Group C. The duration of corneal anes‐
thesia and globe akinesia was significantly higher (P < 0.001) in both Group D50 and Group
D25 in compared to Group C [Table 2].

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Resolution of motor blockade required >6 h in 24 patients in the group D50 (80%) and 20 pa‐
tients in the group D25 (66%) as compared to 14 patients in Group C (47%). Duration of post‐
operative analgesia was longer in Group D50 (P < 0.001) and group D25 (P < 0.001) in compar‐
ing to Group C. These patients also required significantly (P < 0.001) smaller doses of rescue
analgesic during 24 hours [Table 3]. The number of patients with no pain was always higher in
the group D50 (1 h: 29 [96%]; 6 h: 28 [93%]; 24 h: 26 [86%]) and group D25 (1 h: 26 [93%]; 6
h: 22 [73%]; 24 h: 23 [76%]) than in the group C (1 h: 18 [60%]; 6 h: 12 [40%]; 24 h: 17
[56%]) [Figure 1]. During the first day after surgery 17 patients in Group C (56%), 26 patients
in the group D50 (86%), 24 patients in the group D25 (66%) did not require pain medication;
this difference statistical significant (P < 0.0001, P < 0.0001).

IOP was increased significantly (P < 0.001) in group C at 1 minute after injection as compared
to group D50 and D25 where an increase in IOP was minimal and not statistically significant (P
= 0.21 /P = 0.17). Decrease in IOP was observed in both group D50 and group D25 at 5 and 10
minutes following peribulbar block which was significant (P < 0.05). However, in group C IOP
was significantly above the baseline both at 5 and 10 minutes following injection [Table 4,
Figure 2].

Mean Ramsay sedation score (RSS) in group D50 was significantly higher than both group C
and group D25 till first 60 minutes after injection. However, in Group D25 RSS scores were
higher than group C till first 20 minutes after injection [Figure 3].

DISCUSSION

In this study, we demonstrated that in patients undergoing peribulbar anesthesia for cataract
surgery, dexmedetomidine, added to local anesthetics in two different doses, shortens corneal
anesthesia and globe akinesia onset time and extends block duration.

In peribulbar anesthesia, though it has been demonstrated in some studies that clonidine
added to local anesthetics extended the duration of anesthesia and increased the quality of the
block,[4] in their study with 1.5-μg/kg clonidine to Mepivacaine 3%-Hyaluronidase solution,
Hala M et al.,[4] reported that there was no significant difference regarding sensory and motor
block onset time. However, in this study we found that the onset of sensory and motor block
period was shorter in the dexmedetomidine group than in group without dexmedetomidine.

The mechanism by which α2-adregenic receptor agonist produces analgesia and sedation is
not fully understood but is likely to be multifactorial. Peripherally, α2-agonist produces analge‐
sia by reducing the release of norepinephrine and causing α2-receptor-independent inhibitor
effect on nerve fiber action potential. Centrally, α2-agonists produce analgesia and sedation by
inhibition of substance P release in the nociceptive pathway at the level of the dorsal root neu‐
ron and by activation of α2-adrenoreceptor in the locus coeruleus.[14,15]

There is a significant decrease in the IOP in the dexmedetomidine groups in our study. Madan
R et al.[16] found the similar result when added Clonidine to Lidocaine in cataract surgery
done by peribulbar block.

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The effect of dexmedetomidine on the IOP may be due to its direct vasoconstrictor effect on
the afferent blood vessels of the ciliary body leading to reduction of aqueous humor produc‐
tion.[17] It may also facilitate the drainage of aqueous humor by reducing sympathetically me‐
diated vasomotor tone of the ocular drainage system.[18] Finally, the hemodynamic effect of
dexmedetomidine can be responsible for reduction of IOP.[19]

This study demonstrates that addition of local anesthetic with dexmedetomidine provides se‐
dation effectively without causing respiratory depression. Dexmedetomidine sedation enables
full cooperation and potentially better operating conditions without significant respiratory de‐
pression.[20]

CONCLUSIONS

Dexmedetomidine is a useful drug in combination with bupivacaine and lidocaine in peribulbar

anesthesia, as it shortens sensory and motor block onset time, extends motor and sensory
block durations, extends the analgesia period, significantly decreases the IOP and provides se‐
dation which enables full cooperation and potentially better operating conditions.

Footnotes

Source of Support: Nil

Conflict of Interest: None declared.

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13. Browner WS, Black D, Newman B, Hulley SB. Estimating sample size and power. In: Hulley SB, Cummings SR,
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14. Eisenach JC, De Kock M, Klimscha W. Alpha (2)-adrenergic agonists for regional anesthesia. A clinical review of
clonidine (1984-1995) Anesthesiology. 1996;85:655–74. [PubMed: 8853097]

15. Guo TZ, Jiang JY, Buttermann AE, Maze M. Dexmedetomidine injection into the locus ceruleus produces
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16. Madan R, Bharti N, Shende D, Khokhar SK, Kaul HL. A dose response study of Clonidine with local anesthetic
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18. Vartianinen J, MacDonald E, Urtti A, Ronhiainen H, Virtanen R. Dexmedetomidine induced ocular hypotension in
rabbits with normal or elevated intraocular pressure. Invest Ophthalmol Vis Sci. 1992;33:2019–23. [PubMed: 1349879]

19. Georgiou M, Parlapani A, Argiriadou H, Papagiannopoulou P, Katsikis G, Kaprini E. Sufentanil or clonidine for
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20. Muttu S, Liu EH, Ang SB, Chew PT, Lee TL, Ti LK. Comparison of dexmedetomidine and midazolam sedation for
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Figures and Tables

Table 1

Demographic characteristics, duration of surgery

Table 2

Onset and duration of corneal anesthesia and globe akinesia

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Table 3

Duration of analgesia and postoperative analgesic requirement

Figure 1

5 point Verbal rating scale score measured 1, 6, and 24 h after surgery in patients receiving peribulbar anaesthesia in
Group-C (n-30), Group D 50 (n-30) and Group D 25 (n-30)

Table 4

Changes in intraocular pressure (mmHg)

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Figure 2

Graphical representation of intraocular pressure changes during first 10 minutes after peribulbar injection. Data pre‐
sented as mean IOP (mmHg). Decrease in IOP was observed in both group D 50 and group D 25 at 5 minutes and 10 min‐
utes following peribulbar block which was significant (P<0.05)

Figure 3

Graphical presentation of Ramsay sedation score during first 120 minutes. Sedation scores in Group D 50 were signifi‐
cantly higher between 10 to 60 minutes as compared to control group. In group D 25 sedation scores were higher than
control group till first 20 minutes

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