Remifentanil obtunds intraocular pressure rises associated with suxamethonium
Worcester, UK
* E-mail: julieirobin{at}aol.com
Editor—We read the article by Mowafi and colleagues1 with interest. Although the clinical risk of administering suxamethonium chloride for patients with open eye injuries has been questioned, strategies for reducing this rise in associated intraocular pressure (IOP) have been published.2 3 The authors in their discussion barely touched on the use of opioids with no mention of remifentanil. Several studies have now been published where researchers have demonstrated the successful obtunding of the rise in IOP associated with the administration of suxamethonium in adults and children.4–6 A bolus dose of remifentanil >0.5 µg kg–1 has been shown to be as effective as larger doses of alfentanil.6 One advantage of using this opioid is its very short half-life compared with fentanyl and alfentanil. We do not think a discussion of the management of this potential clinical problem is complete without the mention of remifentanil.
Al-Khobar, Saudi Arabia
* E-mail: hany_mowafi{at}hotmail.com
Editor—We thank Drs Robin and Alexander for their interest in our article1 and for extending the discussion to other agents which have been proven to be effective in reducing suxamethonium-induced rise in IOP. Although there was no report of vitreous extrusion that can be attributed solely to the use of suxamethonium,7 there is a growing consensus to limit its use in open globe injuries to difficult airway cases with salvageable eye situations. In such situations, as mentioned in our manuscript, several strategies, including pretreatment with narcotics, can be used to blunt suxamethonium, laryngoscopy, and intubation-induced increases in IOP. Remifentanil is one of the narcotics which have been found beneficial in this respect.4–6 Remifentanil, however, in common with other narcotics, produces dose-dependent respiratory depression, hypotension, bradycardia, and muscle rigidity. Nausea and vomiting are also side-effects of importance after ophthalmic surgery, including open globe injury. Although the ultra-short half-life of the drug results in short-lived side-effects, it may necessitate the administration of other opioids or neuromuscular blocking agents to prevent coughing which can result in increase in the IOP when the effect of suxamethonium wears off as recommended by Dr Alexander himself.4 Lastly, dexmedetomidine has, in addition to its analgesic and ocular hypotensive actions, sedative effects which make it suitable as premedication for ophthalmic surgery, particularly open eye injury.8
References
1 Mowafi HA, Aldossary N, Ismail SA, Alqahtani J. Effect of dexmedetomidine premedication on the intraocular pressure changes after succinylcholine and intubation. Br J Anaesth (2008) 100:485–9.
2 Vinik HR. Intraocular pressure changes during rapid sequence induction and intubation: a comparison of rocuronium, atracurium, and succinylcholine. J Clin Anesth (1999) 11:95–100.[CrossRef][Web of Science][Medline]
3 Chiu CL, Jaais F, Wang CY. Effect of rocuronium compared with succinylcholine on intraocular pressure during rapid sequence induction of anaesthesia. Br J Anaesth (1999) 82:757–60.
4 Alexander R, Hill R, Lipham WJ, et al. Remifentanil prevents an increase in intraocular pressure after succinylcholine and tracheal intubation. Br J Anaesth (1998) 81:606–7.
5 Ng HP, Chen FG, Yeong SM, Wong E, Chew P. Effect of remifentanil compared with fentanyl on intraocular pressure after succinylcholine and tracheal intubation. Br J Anaesth (2000) 85:785–7.
6 Kaygusuz K, Toker MI, Kol IO, et al. The effects of different doses of remifentanil on intraocular pressure after tracheal intubation: a randomized, double-blind and prospective study. Ann Ophthalmol (2007) 39:198–204.[CrossRef][Web of Science]
7 Chidiac EJ, Raiskin AO. Succinylcholine and the open eye. Ophthalmol Clin North Am (2006) 19:279–85.[Medline]
8 Gerlach AT, Dasta JF. Dexmedetomidine: an updated review. Ann Pharmacother (2007) 41:245–52.
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