Evaluation of postoperative discomfort after strabismus surgery under general anesthesia in children: a prospective observational study

doi:10.21203/rs.3.rs-2271387/v2

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Evaluation of postoperative discomfort after strabismus surgery under general anesthesia in children: a prospective observational study

https://doi.org/10.21203/rs.3.rs-2271387/v2

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Introduction: Strabismus surgery is most commonly performed on children under general anesthesia. However, few studies have focused on the postoperative discomfort in children after strabismus surgery.

Methods: A single-center prospective observational study including 300 children who underwent strabismus surgery after general anesthesia was conducted. Patients’ characteristics, preoperative anxiety, surgical and anesthesia data, discomfort within 24 hours after postanesthesia care unit were recorded.

Results: Approximately 61.33% of the children complained of at least one of the following types of discomfort. Multivariate analysis indicated that history of PONV (P=0.999), history of motion sickness (P<0.001, odds ratio [OR]=3.72), and surgery in the dominant eye (P=0.010, OR=2.00) were independent predictors of postoperative discomfort; age was an independent predictor of EA (P<0.001, OR=0.33); prism diopter≥40 was an independent predictor of headache (P=0.005, OR=5.53); age (P=0.020, OR=1.12) and history of motion sickness (P=0.001, OR=2.80) were independent predictors of dizziness; history of PONV (P=0.999), history of motion sickness (P=0.001, OR=2.63), and surgery of inferior oblique anterior transposition (IOAT) (P=0.004, OR=3.10) were independent predictors of PONV.

Conclusion: Younger age, larger angle of strabismus, history of motion sickness, history of PONV, surgery on the dominant eye, and IOAT may be risk factors for postoperative discomfort.

strabismus surgery

postoperative nausea

vomiting

general anesthesia

pediatrics.

Strabismus refers to misalignment of the eyes. The definitive treatment for most cases of primary and secondary strabismus is extraocular muscle (EOM) surgery, particularly when the strabismus has been stable for several months [1]. For children, the management of pain and compliance during the operation requires general anesthesia. General anesthesia can fully relax and expose the EOMs and the maximum squint angle, which is widely used in strabismus surgery. For adult patients, discomfort after general anesthesia is defined as "sensation other than pain" and includes nausea, vomiting, headache, and dizziness [2, 3]. To date, some studies have focused on postoperative discomfort in ophthalmic surgery. A study of a tactile scale in children undergoing ophthalmic surgery found that the majority experienced mild to severe pain and 56% had nausea and/or vomiting [3]. Ye’ study [2] on postoperative pain and discomfort in patients who underwent oculoplastic surgery under general anesthesia showed that anxiety was a risk factor for both postoperative pain and discomfort, while smoking history and prior surgery on the operative eye may be associated with postoperative pain. Similarly, Huang et al [4] reported that 94.76% of adult patients experienced mild discomfort after ambulatory strabismus surgery under general anesthesia; independent predictors of postoperative discomfort included female sex, inferior rectus surgery, mild anxiety, and inferior oblique surgery.

Many previous studies have assessed postoperative nausea and vomiting (PONV), emergence agitation (EA), as well as their risk factors, in the pediatric population. The following are well-known risk factors: history of PONV or motion sickness, strabismus surgery, anesthesia for more than 45 minutes, age > 5 years, opioid use [5–8]. PONV risk scores have been applied to reduce the rate of PONV and can be used to inform and guide therapy. At present, PONV risk scores available in clinical practice include the Apfel simplified risk score [9], post-discharge nausea and vomiting risk score [10], Koivuranta risk score [11], and Eberhart risk score [5]. EA is one of the most common complications in children under general anesthesia and may be associated with a higher incidence of self-injury and recovery interference, as well as increased medical costs [12–14]. Dexmedetomidine, a selective α2-adrenoceptor agonist, has been reported to significantly reduce EA incidence in children after sevoflurane anesthesia [15]. The evaluation of preoperative anxiety may be valuable in identifying children who are at risk of developing postoperative agitation. Several studies have indicated that higher levels of preoperative anxiety are associated with an increased incidence of EA [16, 17]. In addition, the residual effect of anesthetics and inadequate hydration have been observed to be related to postoperative dizziness [18]. However, few studies have focused on postoperative discomfort and risk factors in children after strabismus surgery. Strabismus surgery is most commonly performed on children [19–21] who have a limited ability to express discomfort, which makes it difficult to provide discomfort management. To provide a theoretical basis for developing a more targeted intervention plan to improve postoperative discomfort in children with strabismus, our study aimed to evaluate postoperative discomfort and its risk factors in 300 children who underwent strabismus surgery within 24 hours after general anesthesia.

Patients

Three hundred consecutive pediatric patients (age ≤ 14 years) who underwent strabismus surgery under general anesthesia were recruited from the Zhongshan Ophthalmic Center in Guangzhou, China, from December 2021 to February 2022. The exclusion criteria were as follows: (1) combined with other ophthalmic surgeries, (2) mental illness, (3) inability to communicate (including sensory impairment), and (4) declined to participate. All surgeries were performed by senior strabismus surgeons.

Anesthetic procedure

All patients received intravenous injection of propofol (1.5–2.5 mg/kg) and fentanyl (1–2 µg/kg), combined with a muscle relaxant (cisatracurium, 0.1–0.2 mg/kg), for anesthesia induction and underwent placement of a laryngeal mask airway. Non-steroidal anti-inflammatory and analgesic drugs (flurbiprofen axetil, 1 mg/kg, intravenous [IV]) or nalbuphine (0.1 mg/kg, IV) were used to prevent postoperative pain. Dexamethasone (0.1 mg/kg, IV) combined with a 5-HT3 receptor antagonist (palonosetron, 0.005 mg/kg, or dolasetron, 0.35 mg/kg) was administered intravenously during induction of anesthesia to prevent PONV. Penehyclidine (0.01 mg/kg, IV) was used to reduce respiratory secretions. Intraoperative anesthesia was maintained using total intravenous anesthesia (propofol + remifentanil) or inhalation anesthesia (sevoflurane). Mechanical ventilation was performed through the laryngeal mask airway; tidal volume was 8–10 mL/kg, respiratory rate was 15–20 bpm, and intraoperative end-tidal CO2 was maintained at 35–45 mmHg.

Data collection

All data were obtained by two trained investigators. On the day before the operation, face-to-face interviews with patients and their parents or legal guardians were conducted to collect patient clinical characteristics, and the degree of preoperative anxiety was evaluated using the Chinese version of the modified Yale Preoperative Anxiety Scale (CmYPAS). The clinical characteristics included age, sex, body mass index (BMI), chronic diseases, history of ophthalmic surgery, anesthesia, analgesics and sedatives, PONV and motion sickness, family history of PONV, sleep state, fasting time, and angle of strabismus. The CmYPAS is a reliable observational behavioral scale that is applied to assess preoperative anxiety in children aged 2–12 years [22]. This scale consists of five dimensions: activity, occurrence, emotional expression, obvious alertness, and dependence on parents. The CmYPAS score ranges from 23.33–100 points. The higher the score, the higher the degree of pre-operative anxiety. The cut-off score of “no, mild anxiety” and “moderate and severe anxiety” was 42.78.

Discomfort, surgical, and anesthesia data were recorded the day following the operation. In the present study, the types of discomfort included EA, dizziness, headache, and PONV within 24 hours after post-anesthesia care unit (PACU). EA was evaluated on a 4-point scale: 1 = asleep, calm; 2 = mildly agitated but easily consolable; 3 = moderately agitated or restless and inconsolable; and 4 = hysterical, crying inconsolably, or thrashing [23, 24]. In this study, EA was considered when the score was the same ≥ 2.

Statistical analysis

Statistical descriptions are expressed as the mean ± standard deviation or median (interquartile range) for non-normally distributed variables or the frequency and proportion for categorical variables. An independent sample t-test was used to compare continuous variables with a normal distribution, and the Mann–Whitney U test was used to analyze data that were not normally distributed. Categorical variables between the groups were tested using the chi-square test or Fisher’s exact test. Factors associated with discomfort were analyzed using a logistic regression model. Candidate variables with P < 0.1 on univariate analysis were included in the multivariable model. Statistical significance was set at P < 0.05. All data were analyzed using SPSS software (version 25.0, Chicago, IL, USA).

A total of 300 participants (155 males and 145 females) were recruited for this study. The median age was 8.11 ± 3.13 years. The median CmYPAS score was 30.94 ± 11.53. Eleven percent of the participants experienced moderate severe preoperative anxiety. The children’s basic characteristics are presented in Table 1.

Table 1

Demographics and Characteristics of the Participants (n = 300)
Variable	Statistics
Sex, male/female, n	155/145
Age, years, mean ± SD	8.11 ± 3.13
BMI, kg/m², mean ± SD	17.20 ± 3.28
Chronic disease, n (%)	4 (1.33)
History of ophthalmic surgery, n (%)	20 (6.67)
History of anesthesia, n (%)	63 (21.00)
History of analgesics and sedative, n (%)	79 (26.33)
History of PONV, n (%)	3 (1.00)
History of motion sickness, n (%)	78 (26.00)
Sleep duration on the night before surgery, hour, mean ± SD	8.14 ± 1.08
Parents' self-rated sleep quality of children
Excellent	113 (37.67)
Good	161 (53.67)
Moderate	18 (6.00)
Poor	8 (2.67)
Very poor	0 (0.00)
CmYPAS score, mean ± SD	30.94 ± 11.53
Fasting time, hour, mean ± SD	11.79 ± 2.63
PD ≥ 50, n (%)	46 (15.33)
Vertical strabismus, n (%)	125 (41.67)
Maintenance of general anesthesia, intravenous/inhalation, n	234/66
Analgesic use during the operation, n (%)
Flurbiprofen axetil	17 (5.67)
Nalbuphine	261 (87.00)
Flurbiprofen axetil + Nalbuphine	22 (7.33)
Duration of phase I recovery, min, median (IQR)	37.00 (29.00–48.00)
Duration of phase II recovery, min, median (IQR)	23.00 (12.00–43.00)
Surgery on the dominant eye, n (%)	105 (37.50)
Number of operative EOMs, mean ± SD	2.24 ± 0.90
Surgery duration, min, median (IQR)	23.00 (17.00–29.00)
Surgery on superior oblique, n (%)	5 (1.67)
Surgery on inferior oblique, n (%)	69 (23.00)
Surgery on superior rectus, n (%)	6 (2.00)
Surgery on inferior rectus, n (%)	1 (0.33)
Surgery of inferior oblique anterior transposition, n (%)	34 (11.33)
Abbreviations: BMI, body mass index; CmYPAS, Chinese version of the modified Yale Preoperative Anxiety Scale; EOMs, extraocular muscles; PD, prism diopter; PONV, postoperative nausea and vomiting

Approximately 61.33% of the children complained of at least one of the following types of discomfort: EA (5.33%), dizziness (20.33%), headache (4.33%), and PONV (23.00%). Among the potential factors investigated in the univariate analysis, nine factors were associated with postoperative discomfort (P < 0.1): age, history of PONV, history of motion sickness, vertical strabismus, number of operative EOMs, surgery on the dominant eye, surgery duration, surgery on the inferior oblique, and surgery of the inferior oblique anterior transposition (IOAT). History of PONV (P = 0.999), history of motion sickness (P < 0.001, odds ratio [OR] = 3.72), and surgery in the dominant eye (P = 0.010, OR = 2.00) were included in the multivariable model.

The results of univariate analysis showed that nine factors were associated with EA (P < 0.1): age, BMI, history of anesthesia, parents' self-rated sleep quality of children, CmYPAS score, prism diopter (PD) ≥ 50, maintenance of general anesthesia, surgery on inferior oblique, and surgery of IOAT (Table 2). Based on multivariate analysis, age was an independent predictor of EA (P < 0.001, OR = 0.33) (Table 2).

Table 2

Univariable and Multivariable Logistic Regression Analysis of Potential Factors of Emergence Agitation (n = 300)
	EA (n = 16)	Non-EA (n = 284)	Univariable Analysis		Multivariable Model
	EA (n = 16)	Non-EA (n = 284)	χ²/t/z	P	OR(95% CI)	P
Age, years, mean ± SD	3.56 ± 1.15	8.36 ± 3.009	-14.158	< 0.001	0.33 (0.21–0.51)	< 0.001
BMI, kg/m², mean ± SD	15.68 ± 1.62	17.28 ± 3.33	-3.572	0.002
History of anesthesia, n (%)	0/16 (0.00)	63/283	3.255	0.071
Parents' self-rated sleep quality of children			14.702	0.002
Excellent	11 (68.75)	102 (35.92)
Good	2 (12.5)	159 (55.99)
Moderate	3 (18.75)	15 (5.28)
Poor	0 (0.00)	8 (2.82)
Very poor	0 (0.00)	0 (0.00)
CmYPAS score, mean ± SD	45.31 ± 19.32	30.13 ± 10.41	3.117	0.007
PD ≥ 50, n (%)	6/16 (37.50)	40/244 (16.39)	4.720	0.030
Maintenance of general anesthesia, intravenous/inhalation, n	16/0	218/66	3.509	0.061
Surgery on inferior oblique, n (%)	8/16 (50.00)	61/284 (21.48)	5.440	0.020
Surgery of inferior oblique anterior transposition, n (%)	5/16 (31.25)	29/284 (10.21)	4.742	0.029
Abbreviations: BMI, body mass index; CmYPAS, Chinese version of the modified Yale Preoperative Anxiety Scale; CI, confidence interval; EA, emergence agitation; PD, prism diopter

The univariate analysis indicated that age and PD ≥ 40 were associated with headache (P < 0.1). Based on the multivariate analysis, PD ≥ 40 was an independent predictor of headache (P = 0.005, OR = 5.53). Univariate analysis also showed that age and history of motion sickness were associated with dizziness (P < 0.1); these factors were also included in the multivariate analysis (Table 3).

Table 3

Univariable and Multivariable Logistic Regression Analysis of Detecting Potential Factors of Dizziness (n = 300)
	Dizziness (n = 61)	Non-dizziness(n = 239)	Univariable Analysis		Multivariable Model
	Dizziness (n = 61)	Non-dizziness(n = 239)	χ²/t/z	P	OR(95%CI)	P
Age, years, mean ± SD	8.92 ± 3.00	7.90 ± 3.14	-2.284	0.023	1.12 (1.02–1.24)	0.020
History of motion sickness, n (%)	27/61 (44.26)	51/239 (21.34)	13.273	༜0.001	2.80(1.53–5.12)	0.001
Surgery of inferior oblique anterior transposition, n (%)	11/61 (18.03)	23/239 (9.62)	3.420	0.064

During the first 24 hours after PACU, 28 (9.33%) and 41 (13.67%) of the children suffered from nausea and vomiting, respectively. Among the 41 patients with vomiting, 16 (39.02%), 25 (60.98%), 31 (75.61%), 35 (85.37%), and 41 (100.00%) vomited within 2, 4, 6, 12, and 24 hours after PACU. Univariate analysis showed that a history of PONV, motion sickness, vertical strabismus, number of operative EOMs, surgery duration, and IOAT surgery were associated with PONV (P < 0.1) (Table 4). The three factors included in the multivariate analysis were history of PONV (P = 0.999), history of motion sickness (P = 0.001, OR = 2.63), and surgery of IOAT (P = 0.004, OR = 3.10) (Table 4).

Table 4

Univariable and Multivariable Logistic Regression Analysis of Detecting Potential Factors of PONV (n = 300)
	PONV(n = 69)	Non-PONV(n = 231)	Univariable Analysis		Multivariable Model
	PONV(n = 69)	Non-PONV(n = 231)	χ²/t/z	P	OR(95%CI)	P
History of PONV, n (%)	3/69 (4.35)	0/231 (0.00)	/	0.012	-	0.999
History of motion sickness, n (%)	29/69 (42.03)	49/231 (21.21)	11.966	0.001	2.63 (1.46–4.76)	0.001
Number of operative EOMs, mean ± SD	2.55 ± 0.98	2.15 ± 0.85	-3.292	0.001
Surgery duration, min, median (IQR)	21.00 (20.00–31.00)	23.00 (17.00–29.00)	-2.549	0.011
Surgery on inferior oblique, n (%)	23/69 (33.33)	46/231 (19.91)	5.403	0.020
Surgery of inferior oblique anterior transposition, n (%)	15/69 (21.74)	19/231 (8.23)	9.656	0.002	3.10 (1.45–6.64)	0.004
Abbreviation: PONV, postoperative nausea and vomiting; EOMs, extraocular muscles.

Strabismus surgery in children has been associated with a higher risk of PONV than other surgical procedures [25]. The proposed mechanisms include the stimulation of the oculo-emetic reflex during traction on the extra-ocular muscles and alterations in visual perception postoperatively [26]. There were 69 children (23.00%) who had PONV in this study, while previous studies have reported incidence rates ranging from 18 to 68.2% [27–29]. We found that more than half of the children vomited within 4 hours after PACU. Previous studies have indicated that emesis after strabismus surgery tend to occur after 2–8 hours, rather than immediately postoperatively. At present, there is no PONV risk score for patients with strabismus. Some studies have reported independent risk factors of PONV in patients with strabismus. Li et al. [30] showed that the duration of surgery was an independent risk factor for PONV, with a cut-off point of 29.5 minutes, sensitivity of 1.00, and specificity of 0.64. In addition, Huang et al. [4] reported that female sex, inferior rectus surgery, and inferior oblique surgery were independent risk factors for adult postoperative vomiting. Similar to previous studies, we found that a history of PONV or motion sickness and IOAT were risk factors for PONV in children who underwent strabismus surgery. A history of PONV or motion sickness has been identified as a risk factor for pediatric PONV in a previously established guideline [6]. Furthermore, different surgical procedures for the EOM have also been associated with PONV [31]. Lerman [32] demonstrated that the probability of PONV increased as the operative EOM increased. Therefore, the inferior oblique muscle, which is less accessible during surgery, may be more likely to lead to PONV. IOAT is an effective procedure for weakening inferior oblique overaction coexisting with dissociated vertical deviation [33], which is technically more challenging than other inferior oblique-weakening procedures [34]. The mechanisms underlying IOAT and PONV remain unclear. Further studies need to be conducted to confirm the potential mechanisms between the inferior oblique and PONV.

In the present study, 20.33% of patients complained of dizziness during the first 24 hours after surgery. In contrast, Huang et al. reported that 28.57% of adult patients felt dizziness. Previous studies explained that dizziness may be due to the residual effect of anesthetics, inadequate hydration, and surgical outcome [18, 35]. The results of the multivariate analysis in this study showed that age and history of motion sickness were significantly associated with dizziness. Few studies have evaluated motion sickness in patients who underwent surgery under general anesthesia. Our data indicate that a history of motion sickness may be a critical independent predictor of dizziness symptoms in children.

While a number of previous studies have focused on EA in children in PACU, our study found that 5.33% of children aged 2–5 years experienced EA after they were transferred to the ward. Consistent with previous studies [36–38], we found that age is a significant predictor of EA in children. The incidence of EA in strabismus surgery is still high, not only due to the anesthesia course mainly consisting of sevoflurane and the fear of dressing coverage but also because of the distressing preoperative period [39].

Various potential risk factors for postoperative discomfort were also identified in the present study. Notably, we found that surgery in the dominant eye and surgery of IOAT were predictors of postoperative discomfort. Therefore, these factors may facilitate symptom management by ophthalmologists. Moreover, we observed that vomiting tended to occur within 4–6 hours after PACU, indicating that child caretakers may be more attentive within this time frame.

This study had some limitations. First, this was a cross-sectional study that was conducted in a single center. Larger cohort studies are required to confirm the risk factors for postoperative discomfort in children after strabismus surgery under general anesthesia. Second, the surgeries were performed by different senior strabismus surgeons and the differences among surgeons were not analyzed in this study. Third, considering total intravenous anesthesia and inhalation anesthesia may cause postoperative symptoms to varying degrees, we analyzed this factor. Therefore, there was no standardized anesthesia protocol in this study. Finally, while a history of PONV and a family history of PONV are proven risk factors for pediatric PONV, only a few children in our study had these risks. Although a history of PONV was included in the regression model, the odds ratio was unclear due to the small sample size. Future multicenter studies with larger sample sizes are required to confirm the results of the present study.

In conclusion, the most common postoperative symptoms experienced by children after strabismus surgery (under general anesthesia) are PONV, dizziness, EA, and headache. A history of PONV or motion sickness and IOAT were the defining risk factors for PONV. Age and a history of motion sickness were independent risk factors for postoperative dizziness. The independent risk factors for EA and headache were a younger age and larger strabismus angle, respectively. Prospective identification of the factors associated with postoperative discomfort should provide a theoretical basis for developing a more targeted intervention plan to improve postoperative discomfort in patients with strabismus.

Statements

Acknowledgement

The authors wish to thank the children and their parents or legal guardians who took part in this study, as well as our colleagues in the anesthesia research team and department of strabismus and amblyopia at our center.

Statement of Ethics

The study was conducted according to the guidelines of the Declaration of Helsinki. This study protocol was reviewed and approved by the Ethics Committee of the Zhongshan Ophthalmic Center, Sun Yat-sen University. Written informed consent was obtained from the participants' parent/legal guardian in the study.

Conflict of Interest Statement

The authors have no conflicts of interest to declare.

Funding Sources

This manuscript did not receive any funding.

Author Contributions

M.Y. and Z.W. contributed equally to this work. M.Y. and Z.W. performed the data acquisition and analysis, wrote the main manuscript text; T.X. ,W.Y. and Z.R. contributed to conception, design this study; Z.L. revised the manuscript critically. All authors read and approved the final manuscript.

Data Availability Statement

All data generated or analysed during this study are included in this article. Further enquiries can be directed to the corresponding author.

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Evaluation of postoperative discomfort after strabismus surgery under general anesthesia in children: a prospective observational study

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Abstract

Introduction

Materials And Methods

Patients

Anesthetic procedure

Data collection

Statistical analysis

Results

Discussion

Statements

Declarations

Statement of Ethics

Conflict of Interest Statement

Funding Sources

Author Contributions

References

Additional Declarations

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