glyco or atropine for peds eye cases?

[climbingdocs]

I have not done official peds rotation yet, but I am doing peds eyes tomorrow, what to use for oculocardiac reflex, glyco or atropine? And what dose?
thanks!

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[2ndyear]

First step is to stop traction. That usually solves it.

 

[btbam]

atropine 0.01 mg/kg if surgeon stopping doesn't improve the brady.

 

[jwk]

First step is to stop traction. That usually solves it.

Pre-cordial thumps while the surgeon is under the microscope always makes your point.

 

[Idiopathic]

i always used atropine for kids. just felt it was more reliable

 

[Matty44]

I agree with atropine, but I wouldn't give less than 0.02 mg/kg (or <0.1 mg overall dose) as you may get a paradoxic bradycardia.

 

[IlDestriero]

I agree with atropine, but I wouldn't give less than 0.02 mg/kg (or <0.1 mg overall dose) as you may get a paradoxic bradycardia.

Those with grey hair may not necessarily agree with the above, however 10 mcg/kg with a 100 mcg minimum dose is reasonable for almost everyone. There are some who pass through my Children's hospital with the idea that 0.16mg is the minimum "safe" dose. I'm not sure where that came from, and I disagree with that.

 

[Matty44]

Those with grey hair may not necessarily agree with the above, however 10 mcg/kg with a 100 mcg minimum dose is reasonable for almost everyone. There are some who pass through my Children's hospital with the idea that 0.16mg is the minimum "safe" dose. I'm not sure where that came from, and I disagree with that.

I confess I haven't seen any literature on the 0.02mg/kg dose. I have had more than one pediatric attending tell me never to give less than that dose though d/t the possible bradycardia. My experience is obviously still very limited so I haven't any clinical examples to back that up...has anyone one here ever seen trouble with the 0.01mg/kg dose, or is the consensus that as long as you give over 0.1 mg total, you are fine using as little as 0.01mg/kg?

 

[Idiopathic]

have never given less than 0.1mg, but rarely have given much more than 0.2mg and have never had a problem

 

[Sergio99]

First step is to stop traction. That usually solves it.

I agree. It "USUALLY" solves it, but not always.

In general there are two approaches:

A) pretreatment with atropine or glycopyrrolate
B) rescue treatment with atropine when the event happens

-1) Pretreatment is shunned by many who consider it unnecessary, because serious problems are very uncommon and the reflex "USUALLY" responds to stopping the traction
-2) Pretreatment doesn't always prevent the reflex, but merely attenuates it

Above all, remember that sometimes not even atropine helps and you may have to resort to epinephrine or cardiac compressions, so be prepared for that eventuality; keep a ready filled syringe of epinephrine and pray you won't have to use it.

In general, the use of local anesthetics to block the reflex is not effective.

These recommendations come from Coté-Lerman-Todres (2008) and Smith's textbook, by Davis-Cladis-Motoyama, (2011)

 

[HalO'Thane]

My observation has also been that the reflex usually resolves when the surgeon stops traction, is fatiguable (i.e. not as dramatic with each subsequent traction), and usually does not result in any major hemodynamic alteration. If it does, atropine 10-20 mcg/kg (100 mcg min) usually does the trick. Another observation I have made is that since I have started routinely intubating my smaller strabismus surgery kids I have not seen it nearly as much. I have read that hypercapnia can greatly increase the risk of the OCR, which would be much more likely in a spontaneously breathing patient with an LMA. Has anyone else noticed this?