Retrobulbar Block

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SAMPLE EXCERPT
- Full procedure text, video and illustrations available with the full product
Editor(s): Lee A. Fleisher, MD, FACC, FAHA Lee A. Fleisher, MD, FACC, FAHA

Robert Dunning Dripps
Professor and Chair
Department of Anesthesiology and Critical Care

Professor of Medicine
University of Pennsylvania School of Medicine
| Robert Gaiser, MD Robert Gaiser, MD

Professor of Anesthesiology and Critical Care
Department of Anesthesiology and Critical Care
University of Pennsylvania School of Medicine

Contributor(s): Nabil Elkassabany, MD Nabil Elkassabany, MD

Clinical Assistant Professor of Anesthesiology and Critical Care
Veterans Administration Hospital
| Michael Sulewski, MD Michael Sulewski, MD

Clinical Associate Professor
Department of Ophthalmology
University of Pennsylvania School of Medicine

Chief of Ophthalmology
Director, Cornea and External Diseases Service
Philadelphia Veterans Administration Medical Center
Philadelphia, PA
| Acknowledgements Acknowledgements

VIDEO EDITOR
Jeremy D. Kukafka, MD
Faculty
Department of Anesthesiology and Critical Care
Univ of Pennsylvania School of Medicine
Philadelphia, PA

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MEDICAL WRITER
Gail A. Van Norman, MD
Clinical Associate Professor
Department of Anesthesiology
Univ of Washington
Seattle, WA

MEDICAL AND VIDEO EDITOR AND SUBJECT MATTER EXPERT
Elizabeth J. Watson, MD
Post-Doctoral Fellow
Department of Anesthesiology and Critical Care
Univ of Pennsylvania School of Medicine
Philadelphia, PA

VIDEO COORDINATOR
Liang Xue, BS
Research Assistant
Department of Anesthesiology and Critical Care
Univ of Pennsylvania School of Medicine
Philadelphia, PA

PRE-PROCEDURE
INDICATIONS

Regional anesthesia for intraocular and orbital surgery

CONTRAINDICATIONS

Absolute contraindications

  • Patient refusal
  • Infection at the injection site

Relative contraindications

  • Children less than about 15 years old
  • Globes that are at higher risk for perforation, especially eyes with an axial length greater than 26 mm or eyes with known posterior staphylomas
  • Procedures lasting significantly more than 90 minutes
  • Uncontrolled cough, tremor, or convulsive disorder
  • Disorientation or mental impairment
  • Excessive anxiety or claustrophobia
  • Language barrier or deafness
  • Bleeding or coagulation disorders (some surgeons will proceed despite mild coagulopathy)
  • Inability to lie flat
EQUIPMENT
  • Sterile gloves
  • Prep swab, such as alcohol or Betadine
  • Resuscitation equipment, including oxygen and appropriate resuscitation medications
  • Monitors, including ECG, blood pressure cuff, and pulse oximeter
  • Local anesthetic (a mixture of bupivacaine 0.75% and lidocaine 2%)
  • 5-mL syringe
  • 30-gauge needle for skin wheal injection
  • 35-mm blunt tip 25-gauge needle (Atkinson retrobulbar needle)
ANATOMY
  • The orbit is a cone-shaped space, with its base at the front of the skull and the apex pointed posteromedially toward the center of the skull. The optic foramen is at the apex of the pyramid and transmits the optic nerve and blood vessels.
  • The globe is anterior and superior within the orbit.The sclera is a fibrous layer completely surrounding the globe except the cornea. Three muscle pairs move the globe within the orbit: the superior, medial, and inferior rectus muscles.
  • Nerve supply to the eye: Motor supplyis derived from cranial nerves III, IV, and VI. Sensation is via the trigeminal nerve (cranial nerve V). Cranial nerve II (optic nerve) is responsible for vision.
  • The ciliary ganglion is a parasympathetic ganglion lying about 1 cm from the posterior border of the orbit.
  • Retrobulbar block anesthetizes the ciliary ganglion, ciliary nerves, and cranial nerves III, IV, and VI.
  • The orbicularis oculi surrounds the orbit and obtains its nerve supply from the zygomatic branch of the facial nerve (cranial nerve VII).

PROCEDURE
Sample excerpt does not include step-by-step text instructions for performing this procedure
The full content of this section includes:
  • Step-by-step text instructions for performing the procedure
  • Clinical pearls providing practical clinical tips from medical experts
  • Patient safety guidelines consistent with Joint Commission and OHSA standards
  • Links to medical evidence and related procedures

POST-PROCEDURE
CARE
  • Make the patient comfortable in the operating theater using pillows and pads as required.
  • Observe the patient for signs of retrobulbar hemorrhage.
  • Use a right angle screen to keep the drapes away from the patient’s face and to support an oxygen delivery system.
  • Use a high flow of oxygen (8 L/min) to increase the Fio2 and prevent CO2 accumulation.
  • Use sedation judiciously.
COMPLICATIONS
  • Retrobulbar hemorrhage
  • Oculocardiac reflex
  • Central retinal artery occlusion
  • Puncture of the posterior globe
  • Penetration of the optic nerve
  • Unintended brain stem anesthesia
  • Local anesthetic toxicity
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