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Year : 2020  |  Volume : 14  |  Issue : 2  |  Page : 203-207  

Acceptability and feasibility of an innovative anesthesia technique in a low-resource setting at a rural community ophthalmic center: A prospective journey

1 Department of Anaesthesiology, Sitapur Eye Hospital and Regional Institute of Ophthalmology, Sitapur, Uttar Pradesh, India
2 Department of Paediatric Ophthalmology, Sitapur Eye Hospital and Regional Institute of Ophthalmology, Sitapur, Uttar Pradesh, India

Date of Submission31-May-2020
Date of Decision05-Jun-2020
Date of Acceptance18-Jun-2020
Date of Web Publication12-Oct-2020

Correspondence Address:
Dr. Shilpi Sethi
Department of Anaesthesiology, Sitapur Eye Hospital and Regional Institute of Ophthalmology, Sitapur - 261001, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aer.AER_46_20

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Background: Ocular blindness and ocular morbidities are very much prevalent in pediatric age group in India. Mostly, these are all surgically amenable, provided they have access to safe anesthesia. Suboptimal facilities for conventional general anesthesia (GA) led to a different thought process. The combination of anesthetic and analgesic property of ketamine was utilized in a low-resource setting at a tertiary ophthalmic center for pediatric ophthalmic surgeries. Aims: The aim of this study was to decipher whether this technique is acceptable and feasible. Settings and Design: It was a prospective consecutive series at a rural eye center done over a period of 5 years. Materials and Methods: Inclusion criterion was children undergoing eye surgeries between the ages of 7 and 18 years, who could be adequately counseled about the concept of painless intravenous cannulation and subsequent painless block. Intravenous anesthesia comprised of ketamine, in conjunction with peribulbar block. Complications of the technique, time to discharge, mean pain score, and patient and surgeon satisfaction score were documented. Statistical Analysis Used: Data were analyzed on Microsoft Excel. Results: A total of 905 cases were conducted uneventfully without conversion to GA. No emergency resuscitation was required. The surgeon and the patient had a satisfying experience, with the technique being totally acceptable to them. Conclusions: Intravenous ketamine is an inexpensive and safe anesthetic technique when used in conjunction with regional block and is certainly a boon for minimal resource ophthalmic setup in rural India.

Keywords: Intravenous anesthesia, ketamine, pediatric ophthalmic surgeries, peribulbar anesthesia, rural hospital

How to cite this article:
Sethi S, Subhedar K, Sharma S, Sethi M. Acceptability and feasibility of an innovative anesthesia technique in a low-resource setting at a rural community ophthalmic center: A prospective journey. Anesth Essays Res 2020;14:203-7

How to cite this URL:
Sethi S, Subhedar K, Sharma S, Sethi M. Acceptability and feasibility of an innovative anesthesia technique in a low-resource setting at a rural community ophthalmic center: A prospective journey. Anesth Essays Res [serial online] 2020 [cited 2021 Jan 21];14:203-7. Available from:

   Introduction Top

It is estimated that 1.26 million children are blind worldwide, with two-thirds being in developing countries. About 30%–40% of children suffer from preventable and treatable cause of blindness such as cataract, corneal injuries, glaucoma, and problems with retina.[1] Combating these issues requires a teamwork of skilled pediatric ophthalmologists and pediatric anesthesiologists.

The developing regions of the world have their own set of limitations such as enormous volume of patients coupled with poor paying capacities. In a limited resource setting lacking advanced inhalational anesthesia delivery systems and a single anesthesiologist catering to the entire pediatric load, an indigenous approach was chalked-out utilizing subanesthetic dose of ketamine. The combination of anesthesia, analgesia, and cardiovascular stability with some preservation of airway reflexes provided by ketamine in the form of total intravenous anesthesia (TIVA), offers an attractive alternative to the conventional general anesthesia (GA). More importantly, it is very cost-effective as well, and this fact cannot be undermined in economically austere rural India.

The aim of this study was to determine the acceptability and feasibility of this innovative technique in children between 7 and 18 years of age who could follow verbal instructions and accordingly be counseled.

   Materials and Methods Top

A prospective study was conducted from 2012 to 2017 over a period of 5 years at a rural eye hospital. After seeking clearance from the institutional ethical committee, a written consent of parents and children was obtained, and the study was conducted in accordance with the standards of Helsinki Declaration. We included children between 7 and 18 years of age with American Society of Anesthesiologists (ASA) I–II posted for various eye surgeries. They were educated about what to expect during the procedure and were explained about the concept of painless intravenous cannulation and subsequent painless peribulbar block or infiltration anesthesia as the case may be. Exclusion criteria included patients' and parents' refusal, mentally challenged children, single-eyed patients, surgery >90 min, globe rupture, and local anesthetic allergy. Children along with parents were seen in preanesthetic checkup (PAC) clinic a day before. A thorough preoperative checkup was done for all patients, and 6 h of fasting guidelines was followed. Weight of all children was documented. Statistical analysis of all the data was done on Microsoft excel sheet.

Prior to cannulation, EMLA cream, which is a eutectic mixture of 2.5% lidocaine w/w and 2.5% prilocaine w/w, was applied under occlusive dressing for 45 min on the dorsum skin of the hand of children on the morning of surgery. This ensured adequate cutaneous analgesia for intravenous (i.v.) cannulation. Premedication was done with injection atropine 0.02 − 1 and on arrival in operation theater, standard monitoring in the form of pulse oximetry and noninvasive blood pressure was applied. Availability of all resuscitation equipment was ensured. All patients received an instillation of topical proparacaine hydrochloride 0.5% in both eyes so as to prevent stinging sensation associated with part preparation. A TIVA technique comprising of a combination of subanesthetic dose of i.v. injection ketamine (0.5 −1) and i.v. injection midazolam (0.05 −1) diluted up to 10 mL given over 30 s was used. This provided sufficient sedation and analgesia so as to allow a needle prick. A 5-mL peribulbar block solution made in 1:1 ratio of 2% xylocaine mixed with 10 IU.mL −1 of hyaluronidase and 0.5% bupivacaine was given with 26G hypodermic needle via the inferotemporal route for intraocular surgeries. In anticipated long duration surgeries, an additional 3 mL of drug was given via medial canthal injection. Similarly, for extraocular surgeries, 2% xylocaine with adrenaline was infiltrated along the incision line and surgical area. During the course of surgery if the need arose, a similar strength solution as the initial bolus of ketamine and midazolam was repeated as and when required. Adverse events were defined as apnea, hypoxemia (pulse oximetry <92%), upper airway obstruction, bronchospasm, and laryngospasm. Interventions, if undertaken, such as intubation or supplemental oxygenation or airway repositioning were to be noted. All children received Ringer Lactate solution as maintenance fluid and an injection ondansetron 8 mg i.v. Each child was nursed in left lateral position and after regaining full consciousness was shifted to the ward. The mean time from postanesthesia care unit (PACU) to discharge to ward was noted. The parents were allowed in the PACU, and an anesthesia assistant inquired about the anesthesia experience in terms of pain and acceptability from children when they were fully conscious. Pain during block and pain at the time of discharge to ward were inquired on Visual Analog Scale (VAS) when the patient was fully conscious. VAS score was graded on a scale of 1–10 where 1 being no pain to 10 being worst pain. Based on VAS score, acceptability was graded as totally acceptable, partially acceptable, and unacceptable as score ranges of 1–3, 4–7, and 8–10, respectively. The surgeon satisfaction scoring was also assessed by Numeric Rating Scale according to the adequacy of operating conditions. It was graded from 1 to 3 where 1 being completely dissatisfied, 2 being partially satisfied, and 3 being completely satisfied.

It was strictly ensured that the surgery was performed by a competent surgeon and not by trainee or inexperienced surgeons. Cataract surgeries included only lens aspiration with intraocular lens implantation without vitrectomy. Vitreoretinal (VR) surgeries included vitrectomy or scleral buckling coupled with endolaser and the squint surgeries included single eye with not more than two muscles.

Statistical analysis used

Data were analyzed on Microsoft excel.

   Results Top

A total of 905 cases were done without any serious side effects. None of the cases were converted to conventional GA. No emergency resuscitation was required. None of the cases required airway manipulation. Transient hypoxemia (SpO2 between 90% and 92%) occurred in 22 patients, which was noted after the initial bolus and reverted spontaneously, not requiring any supplemental oxygen. Dysphoric reactions did occur in few, but were difficult to quantify, more in the 16–18 years' age group. In the age group of 7–10 years, no VR surgeries, dacryocystorhinostomies (DCR), and squint surgeries were done. [Table 1] and [Table 2] show the case distribution according to the type of ocular surgeries, age, and gender. Reinjections were required in a total 303 cases, of which 115 were <10 years of age. Further details of reinjection are given in [Table 3]. After the peribulbar block injection, no case had significant chemosis, and [Table 4] shows the distribution according to the surgeon satisfaction score.
Table 1: Case distribution

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Table 2: Age- and gender-wise distribution of children

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Table 3: Requirement of bolus reinjection

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Table 4: Surgeon satisfaction score

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The mean PACU to discharge time was 175 ± 35.7 min (range 120–240 min). All patients during the peribulbar block/infiltration were in totally acceptable range (1–3) with a mean pain score of 1.83 ± 0.38. The mean pain score at the time of discharge for all patients who underwent cataract, glaucoma, and other surgeries was 2.42 ± 0.49, also categorizing them into totally acceptable range. All the children who underwent DCR and injury repair had partially acceptable pain score with the mean of 4.67 ± 0.47 and 4.82 ± 0.99, respectively. All the children who underwent VR surgery had either partially acceptable (70 patients, 85.4%) or unacceptable scores (12 patients, 14.6%) with a mean score of 4.83 ± 1.39. The patients in partially acceptable range were offered oral analgesics and those in the unacceptable range were offered intravenous tramadol according to body weight.

   Discussion Top

GA is by far the most common anesthetic modality of choice for children undergoing ophthalmic surgeries as the predictability of child's cooperation in regional anesthesia all throughout the procedure is questionable. GA is also not completely innocuous. It has its own intrinsic risks of sore throat and aspiration due to the airway manipulation, coupled with increased incidence of postoperative nausea and vomiting (PONV) and oculocardiac reflex (OCR), which is detrimental in ophthalmic anesthesia.[2] Moreover, emergence phenomenon, which is the hallmark of modern inhalational anesthetics, is known to all.[3] TIVA has numerous advantages over GA in terms of minimal aerosol generation, lesser operating room pollution, avoidance of cross–infection, and minimal emergence risk.[4] In resource-constrained setups, with lack of advanced inhalational anesthesia delivery systems, we resorted to this unique method of peribulbar block in conjunction with sub-anesthetic dosed ketamine.

The choice of ketamine was based on the fact that it is a phencyclidine derivative acting on N-methyl-D-aspartate receptors, which produces dose-related unconsciousness and analgesia, first used by Domino et al.[5],[6] Ketamine at more than 1 − 1 intravenous (i.v.) causes predominant central nervous system effects, more aptly called dissociate anesthesia. In spite of the excellent safety profile, it fell into disrepute earlier because of its psychological emergence reaction and availability of newer anesthetic drugs. Popular TIVA drugs such as propofol were not used as they cause pain on injection and are an antanalgesic. Even dexmedetomidine was avoided because of bradycardia. The concept of subanesthetic doses of ketamine as an adjunct to perioperative analgesia has emerged based on its ability to attenuate central pain sensitization. What constitutes the ideal subanesthetic dose, is also contentious issue, but it has been speculated to range in between 0.15 and 0.5 − 1 i.v. bolus.[7] We used a similar strength of ketamine prior to the placement of block. The effect of this bolus often wears out in around 30 min, so for surgeries of short duration, serial boluses may be repeated.[8] Ketamine causes increased salivation, and an anti-sialagogue medication is warranted. Therefore, we used injection atropine for this purpose, which additionally mitigated the OCR associated with ophthalmic surgeries. It is recommended that benzodiazepines (i.v. midazolam) should be co-administered with ketamine to decrease the incidence of emergence reactions, making them an ideal combination of TIVA drugs.

Previously, there was diminished enthusiasm from the ophthalmologists, regarding the use of ketamine due to its propensity to cause increase in intraocular pressure (IOP),[9],[10] and hence causing poor intraoperative conditions. Now, there is conclusive evidence that doses of ≤4 −1 showed no clinically meaningful association of ketamine with IOP.[11],[12] We measured the surgeon satisfaction score with regard to the operating condition, and our surgeons were reasonably comfortable throughout the procedure.

Given the amount of surgical load and poor infrastructure in terms of equipment/drugs, ketamine has been the backbone of anesthesia services in rural district hospitals of developing world.[13] A large study was conducted by Green et al. to evaluate the safety profile of ketamine in the developing world.[14] Children <15 years were included in this study for operative procedures in the emergency department over a span of 9 years. Out of 431 children, two experienced apnea and four had laryngospasm, which were quickly reversed without any need for intubation. Ketamine was used at a dose of 4 − 1 without any intravenous access. Later, in a retrospective analysis of intravenous ketamine used in 156 children with similar profile, carried out again by Green et al., the only complication noted was transient apnea and that too in one child.[15] Thereby, they concluded that intramuscular (i.m.) and i.v. ketamine are pretty much comparable in terms of safety profile. Thereafter, a meta-analysis was conducted in 2010 by the same group to elucidate the predictors of laryngospasm with ketamine.[16] This was one of the largest case control analyses that indicated that there was no association of age, dose, type of procedure, and the route of administration of ketamine with laryngospasm. We also justify the use of ketamine with excellent safety profile.

Coming to the usage of ketamine in pediatric ophthalmology, an earlier retrospective analysis in children <12 years undergoing examination under anesthesia (EUA) revealed the safety of i.v. ketamine.[17] In this study, a total 149 EUAs were done under ketamine anesthesia and 263 under nonketamine agents such as volatile anesthetics and propofol. Occurrence of airway obstruction, laryngospasm, bronchospasm, and apnea were considered to be respiratory complications (RCs). It came to light that there were increased odds of RC with i.m. ketamine as opposed to i.v. ketamine or nonketamine. There was no statistically significant difference between i.v. and nonketamine groups with respect to RC, however there was an increased risk of RC with volatile anesthetics with ASA III or IV patients. The less likelihood of need to intervene by airway protection in the form of laryngeal mask airway and endotracheal tube in the ketamine group was another scientifically fascinating aspect of this study. A slow titration to a desired anesthetic depth with i.v. ketamine results in decreased overall dose requirement, thus adding to safety as well. We also adopted a similar strategy of securing an i.v. cannula prior and then playing along with subanesthetic dose of ketamine. In our study, the cumulative ketamine dosage never exceeded 2 −1 body weight.

There is emerging evidence that peribulbar block is quite acceptable and feasible in children.[18] In a study by Deb et al., where fifty children between 5 and 14 years of age were randomly allocated to receive peribulbar block as an adjunct to GA versus GA alone.[2] It was demonstrated that there was no any complication of peribulbar block. Rather, it was considered superior in terms of decreased analgesic requirement and reduced incidence of PONV and OCR. Fan et al. from China demonstrated that in the absence of facilities for safe administration of inhalational anesthesia in pediatrics, peribulbar block may be offered after cautious patient selection in children between 7 and 15 years of age.[19] We also used this technique after meticulous patient selection and thorough preoperative detailing. Pun et al. from Nepal conducted a consecutive series of 679 children between ages of 3 months and 18 years under ketamine anesthesia successfully for various intraocular and extraocular surgeries.[20]

Our study showed that none of the children experienced pain at the time of peribulbar block/infiltration, thus implying that this technique was totally acceptable.

In our study, a total of 518 children were completely pain free even at the time of discharge. However, 375 children experienced mild pain, which was taken care with oral analgesics. Only eight children experienced severe pain at full recovery, and they all had undergone scleral buckling surgery, which is a relatively painful procedure per se.

Few other things came to light in our study: bolus dose reinjection was required in all 108 cases of DCR at the time of bone punching. It was observed that the surgeon satisfaction score was 2 (partially satisfied) in 101 cases, out of which 86 children underwent DCR. Thus, DCR may not be the most preferred surgery by this technique, although a couple of studies demonstrated that DCR can be performed with high acceptance rates under LA with intravenous sedation.[21],[22]

Ours is a nonprofit organization, where anesthesia charges for TIVA technique is 1000 INR, whereas the same amounts to 3000 INR for conventional GA. Cost analysis of ketamine with respect to GA was studied in London, where definite cost benefit was shown with i.v. ketamine which was used for the management of displaced pediatric forearm fractures in emergency.[23] Although this was not the primary objective of our study, the huge cuts in the financial burden on already-deprived weaker sections of the society cannot be undermined.

Our study has a limitation that we do not have a control group for comparison. However, a huge sample size concurs to the acceptability and feasibility of this technique.

   Conclusions Top

Given the background of resource-constrained settings, enormity of pediatric ocular morbidity coupled with patients hailing from poor socioeconomic strata, and a single anesthesiologist offering services to one of the oldest eye hospitals in a rural setup, ketamine on account of its excellent safety profile is arguably one of the unique and inexpensive drugs to be used in subanesthetic doses along with peribulbar blocks to children who are adequately counseled and motivated in PAC clinic.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Pascolini D, Mariotti SP. Global estimates of visual impairment: 2010. Br J Ophthalmol 2012;96:614-8.  Back to cited text no. 1
Deb K, Subramaniam R, Dehran M, Tandon R, Shende D. Safety and efficacy of peribulbar block as adjunct to general anaesthesia for paediatric ophthalmic surgery. Paediatr Anaesth 2001;11:161-7.  Back to cited text no. 2
Kocaturk O, Keles S. Recovery characteristics of total intravenous anesthesia with propofol versus sevoflurane anesthesia: A prospective randomized clinical trial. J Pain Res 2018;11:1289-95.  Back to cited text no. 3
Chokshi T, Channabasappa S, Vergheese DC, Bajwa SJ, Gupta B, Mehdiratta L. Re-emergence of TIVA in COVID times. Indian J Anaesth 2020;64:S125-31.  Back to cited text no. 4
Domino EF, Chodoff P, Corssen G. Pharmacologic effects of CI-581, a new dissociative anesthetic, in man. Clin Pharmacol Ther 1965;6:279-91.  Back to cited text no. 5
Chizh BA. Low dose ketamine: A therapeutic and research tool to explore N-methyl-D-aspartate (NMDA) receptor-mediated plasticity in pain pathways. J Psychopharmacol 2007;21:259-71.  Back to cited text no. 6
Gorlin AW, Rosenfeld DM, Ramakrishna H. Intravenous sub-anesthetic ketamine for perioperative analgesia. J Anaesthesiol Clin Pharmacol 2016;32:160-7.  Back to cited text no. 7
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Himmelseher S, Durieux ME. Ketamine for perioperative pain management. Anesthesiology 2005;102:211-20.  Back to cited text no. 8
Wadia S, Bhola R, Lorenz D, Padmanabhan P, Gross J, Stevenson M. Ketamine and intraocular pressure in children. Ann Emerg Med 2014;64:385-8.e1.  Back to cited text no. 9
Corssen G, Hoy JE. A new parenteral anaesthetic C I-581: Its effect on intra-ocular pressure. J Paediatric Ophthalmol 1967;4:20.  Back to cited text no. 10
Nagdeve NG, Yaddanapudi S, Pandav SS. The effect of different doses of ketamine on intraocular pressure in anesthetized children. J Pediatr Ophthalmol Strabismus 2006;43:219-23.  Back to cited text no. 11
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Hodges SC, Walker IA, Bösenberg AT. Paediatric anaesthesia in developing countries. Anaesthesia 2007;62 Suppl 1:26-31.  Back to cited text no. 13
Green SM, Rothrock SG, Lynch EL, Ho M, Harris T, Hestdalen R, et al. Intramuscular ketamine for pediatric sedation in the emergency department: Safety profile in 1,022 cases. Ann Emerg Med 1998;31:688-97.  Back to cited text no. 14
Green SM, Rothrock SG, Harris T, Hopkins GA, Garrett W, Sherwin T. Intravenous ketamine for pediatric sedation in the emergency department: Safety profile with 156 cases. Acad Emerg Med 1998;5:971-6.  Back to cited text no. 15
Green SM, Roback MG, Krauss B, Emergency Department Ketamine Meta-Analysis Study Group. Laryngospasm during emergency department ketamine sedation: A case-control study. Pediatr Emerg Care 2010;26:798-802.  Back to cited text no. 16
Wu L, Lalwani K, Hook KA, Almario BM, Fu R, Edmunds B. Respiratory complications associated with ketamine anesthesia for ophthalmic procedures following intraocular pressure measurement in children. J Anaesthesiol Clin Pharmacol 2014;30:253-7.  Back to cited text no. 17
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Gupta N, Kumar R, Kumar S, Sehgal R, Sharma KR. A prospective randomised double blind study to evaluate the effect of peribulbar block or topical application of local anaesthesia combined with general anaesthesia on intra-operative and postoperative complications during paediatric strabismus surgery. Anaesthesia 2007;62:1110-3.  Back to cited text no. 18
Fan DS, Tang EW, Rao SK, Xiu-Qin Z, Lam DS. The use of peribulbar anaesthesia in paediatric cataract surgery (age 7-15 years) in a mobile eye camp in China. Acta Ophthalmol Scand 2006;84:384-7.  Back to cited text no. 19
Pun MS, Thakur J, Poudyal G, Gurung R, Rana S, Tabin G, et al. Ketamine anaesthesia for paediatric ophthalmology surgery. Br J Ophthalmol 2003;87:535-7.  Back to cited text no. 20
Harissi-Dagher M, Boulos P, Hardy I, Guay J. Comparison of anesthetic and surgical outcomes of dacryocystorhinostomy using loco-regional versus general anesthesia. Digit J Ophthalmol 2008;14:1-6.  Back to cited text no. 21
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  [Table 1], [Table 2], [Table 3], [Table 4]


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