Anaesthesia modalities during laser photocoagulation for retinopathy of prematurity: a retrospective, longitudinal study

Abstract

ObjectivesLaser photocoagulation surgery is a routine treatment for threshold retinopathy of prematurity (ROP). However, little is known about which anaesthesia protocols provide efficient pain control while minimising exposure risk to vulnerable infants. In this study, therefore, we assessed the efficacy and tolerability of multiple anaesthesia techniques used on premature infants during laser therapy.Design and main outcome measuresAnaesthesia modalities consisted of topical eye drops anaesthesia, general anaesthesia and intravenous fentanyl sedation with mechanical ventilation. Laser treatment efficacy and detailed operative information were retrospectively and consecutively analysed. Cardiorespiratory stability was assessed and compared. The Neonatal Pain Agitation and Sedation Scale (N-PASS) was used to evaluate tolerability in infants that underwent intravenous fentanyl sedation.Results97 cases of prematurity were included in this study. In 94/97 (96.9%) cases, vascular proliferation regressed. In the topical anaesthesia groups, the ophthalmologist needed 12–16 min more to complete the treatment. During the 3 postoperative days, topical anaesthesia demonstrated the greatest instability; 4/31 (12.90%) infants in this group suffered from life threatening events requiring resuscitation. The only instability observed in general anaesthesia and fentanyl sedation was attributed to difficulty in extubating within 24 hours after surgery. During laser therapy, the N-PASS score increased to 1.8 in the fentanyl sedation group.ConclusionsTopical anaesthesia was associated with more cardiorespiratory instability during ROP laser treatment. While general anaesthesia and fentanyl sedation had similar postoperative cardiorespiratory results, the latter demonstrated acceptable pain stress control. However, the difficulty of weaning off mechanical ventilation in some cases after surgery needs to be addressed in future studies.

Anesthesia management of laser photocoagulation for retinopathy of prematurity. A retrospective review of perioperative adverse events

“…14 In that study major respiratory events occurred in 9%, reintubation was required in 0.8%, and predictors of adverse events were birth weight < 1.58 kg and PMA < 41 weeks at the time of surgery. 14 In this study, the incidence of apnea and bradycardia is similar to other studies reporting volatile anesthetic techniques for laser photocoagulation 9,10,15,16 ( Table 4). The influence of anesthetic technique on the incidence of perioperative adverse events is unclear.…”

“…This study reinforces the evidence that infants undergoing laser photocoagulation for retinopathy are at high risk of intra-and postoperative adverse events. [9][10][11] There was no evidence that current age, current weight, timing of the procedure, or location of the procedure had an effect on the incidence of perioperative adverse events. In contrast, many studies identify low PMA and low weight as significant risk factors for perioperative adverse events.…”

Neonatal Pain, Agitation, and Sedation Scale’s use, reliability, and validity: a systematic review

“…N-PASS was used to measure acute (e.g., procedural) pain in all neonatal gestational age categories as defined by WHO, including extremely preterm (n = 5) [17][18][19][20][21], very preterm (n = 5) [17,18,[21][22][23], late preterm (n = 5) [10,11,17,21,24], and term infants (n = 7) [17,21,[25][26][27][28][29]. N-PASS was also used to measure acute pain in infants age 1-36 months (n = 1) [30].…”

“…In addition to variation observed by gestational age group and clinical setting, N-PASS was used to measure acute pain in neonatal subpopulations including mechanically ventilated infants (n = 6) [10,11,[18][19][20][21], nonmechanically ventilated infants (n = 8) [18,20,21,23,[27][28][29]32], and postoperative infants (n = 2) [30,32].…”

Literature review informs clinical guidelines for pain management during screening and laser photocoagulation for retinopathy of prematurity

“…A retrospective, longitudinal study of 97 premature neonates used fentanyl (bolus of 2 lg/kg and infusion of 2 lg/kg/h) and achieved good control of pain and stress and the same cardiorespiratory stability as general anaesthesia, namely halothane inhalation and muscle relaxation in the operating theatre (40). Quality of evidence: low Some centres have reported using opioids, generally fentanyl, in appropriate doses, combined with curare ( Table 3).…”