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In Response:
- Hany A. Mowafi, Salah A. Ismail Assistant Professor & Anesthesia Consultant King Faisal University, Damman, Saudi Arabia (29 June 2008)
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Remifentanil obtunds intraocular pressure rises associated with suxamethonium.
- Julie I Robin, Ratan Alexander (19 June 2008)
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Hany A. Mowafi, Assistant Professor & Anesthesia Consultant King Faisal University, Damman, Saudi Arabia, Salah A. Ismail Assistant Professor & Anesthesia Consultant King Faisal University, Damman, Saudi Arabia
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We thank Dr. Robin and Dr. 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 suxamethonium2, there is a growing consensus to limit its use in open globe injuries to difficult airway cases with salvageable eye situations.3 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.1 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. 7 8 Nausea and vomiting are also side effects of importance following ophthalmic surgery, including open globe injury. While 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 more suitable as premedication for ophthalmic surgery, particularly open eye injury.9
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.Libonati MM, Leahy JJ, Ellison N. The use of succinylcholine in open eye surgery. Anesthesiology 1986; 62: 637-40.
3.Chidiac EJ, Raiskin AO. Succinylcholine and the open eye. Ophthalmol Clin North Am 2006; 19: 279-85.
4.Alexander R, Hill R, Lipham WJ, Weatherwax KJ, el-Moalem HE. 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, Erdogan H, Gursoy S, Mimaroglu C. 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.
7.Joo HS, Perks WJ, Kataoka MT, Errett L, Pace K, Honey RJ. A comparison of patient-controlled sedation using either remifentanil or remifentanil-propofol for shock wave lithotripsy. Anesth Analg 2001; 93: 1227–32.
8.Sator-Katzenschlager SM, Oehmke MJ, Deusch E, Dolezal S, Heinze G, Wedrich A. Effects of remifentanil and fentanyl on intraocular pressure during the maintenance and recovery of anaesthesia in patients undergoing non- ophthalmic surgery. Eur J Anaesthesiol 2004; 21: 95-100.
9.Gerlach AT, Dasta JF. Dexmedetomidine: an updated review. Ann Pharmacother 2007; 41: 245-52.
Conflict of Interest:None declared |
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Julie I Robin , Ratan Alexander
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We read the research article published by Mowafi et al with interest1. While 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 published2-3. The authors in their discussion barely touched on 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 larger than 0.5 mcg/kg has been shown to be as effective as larger doses of alfentanil6. 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. 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. 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. Julie Robin SpR Anaesthetics Ratan Alexander Consultant Anaesthetist Department of Anaesthetics Sky Level Worcestershire Royal Hospital Charles Hastings Way Worcester WR5 1DD Correspondence to Julie Robin Department of Anaesthetics Sky Level Worcestershire Royal Hospital Charles Hastings Way Worcester WR5 1DD E-mail julieirobin@aol.com Tel: 01905 760637 Fax 01905 760811 Conflict of Interest:None declared |
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