A retrospective analysis of anesthetic concerns and management of pediatric patients undergoing brachytherapy for retinoblastoma

There is currently no descriptions of the anesthetic management of these patients. We conducted this retrospective analysis to evaluate anxiety scores and assess the efficacy of different techniques to reduce anxiety in children undergoing brachytherapy. We also evaluated postoperative analgesia options and other perioperative challenges. After institutional ethics committee approval, American Society of Anesthesiologists (ASA) classes I/II, children(1–12 years) undergoing brachytherapy for retinoblastoma over 5 years (January 2017–December 2021) at a tertiary center were included. Data was extracted from anesthesia records and case files. Video distraction or parental presence was used to manage preoperative anxiety, and a cannula was inserted after inhalation induction in majority of children who didn't have IV cannula. A combination of fentanyl, acetaminophen, and sub-tenon block was used for perioperative analgesia. Systemic midazolam was administered to patients with an intravenous cannula in situ for anxiety before second surgery. Data was collected, including procedure duration, the interval between procedures, anxiety, perioperative pain using FLACC score, modified Yale Preoperative Anxiety(m-YAPS-SF) Scale before first surgery, and pediatric sedation agitation scale (P-SAS) after midazolam before second surgery, fasting period, anesthetic technique, and postoperative complications. Statistics are primarily descriptive. Continuous variables will be given as a mean value and standard deviation or confidence interval), categorical variables as numbers and percentage. Mean difference was used to illustrate differences between groups. Two of 23 patients were excluded from the study. We failed to contact one attendant for consent and tumor increased in size in other child making it not fit for implant. We therefore able to analyze the data of 21 children who underwent 42 surgeries. The patients' mean (SD) age and weight was 3.3 ± 1.6 yrs. and 14.3 ± 4.2 kg. All children had multiple previous anesthesia exposures (mean 8.0 ± 3.5times). All children had secondary retinoblastoma except one. Eighteen of 21 patients had one eye already enucleated in their past surgeries. All the patients (n = 21) exhibited severe anxiety prior to plaque insertion, with a mean m-YAPS-SF score of 73.4 ± 15.8 (out of 100). The standard routine institutional practice of parental presence did not alleviate preoperative anxiety in the initial 16 patients, as indicated by a mean (95% CI) of 73.4 (65.0, 81.7). We further implemented video distraction along with parental presence for five patients; however, this also failed to result in any clinically significant reductions in mean (CI) anxiety scores [62 (48.4, 75.6)]. The inhalational technique was used in 18 children, and intravenous induction was used for three. All the children received muscle relaxants and positive pressure ventilation with a second-generation supraglottic device. The surgery lasted 48 ± 11 min, and four (19%) were performed outside the routine hours. Systemic analgesics (fentanyl and acetaminophen) were used for all, while six children received an anterior sub-tenon block. The use of subtenon block (n = 15) resulted in superior analgesia, evidenced by a mean FLACC score of 2+/−1.1 compared to 3.6+/−0.98, with a mean difference (CI) of 1.6 (0.5 to 2.6, p = .0041) when compared with systemic analgesics alone (n = 6). The second surgery of plaque removal was done within 24 h in 15/21 patients (Median 19, Range = 7–44 h). We used intravenous midazolam in 12/21 children before second surgery, which resulted in a calmer child as assessed by mean P-SAS score compared to parental presence (n = 12) only (3+/−0.62 vs., 5+/−0.83, mean difference (CI) 2[1.3 to 2.6], p < .0001)The anesthesia technique remained the same except that muscle relaxants were omitted, and surgery was shorter (22 ± 6.5 min). Analgesia was with 1 μg/kg fentanyl and intravenous acetaminophen. Children were vastly comfortable after removal of implant and didn't complain of any significant pain. (M FLAAC = 1.7, 95% CI [1.2, 2.2]). The outcome was complete regression in 77.7%, while four patients had to undergo enucleation. We observed that the baseline anxiety levels were exceedingly high in all these children. This is in comparison to the global incidence of 35%–75%.3 This may be due to multiple previous anesthesia exposures, painful cannulations for chemotherapy, or radiological investigations.4 Literature suggests a potential benefit of video-distraction in reducing preoperative anxiety but role of parental presence is dubious.5, 6 Our analysis found that neither of these interventions was completely effective. Oral premedication was not provided due to the remote location of the procedure room. For the plaque removal surgery, intravenous midazolam was given through an in-situ intravenous cannula, which resulted in calm children and smooth induction. Our analysis found that these children are not amenable to conventional nonpharmacological measures, and sedatives should be added to reduce anxiety. Previous studies have also shown the effectiveness of midazolam through various routes.7 Postoperative pain management was challenging due to the painful procedure of plaque insertion and foreign body sensation. Furthermore, they were practically blind, with one eye enucleated and the other bandaged after surgery. Remote locations of these OTs and radiation risk result in compromised post-operative monitoring, this limited opioid use, and the availability of help in critical situations. This mandates an experienced anesthetist to carry out diligent perioperative planning. All these children experienced mild to moderate pain despite the use of fentanyl and acetaminophen. A multimodal approach, including a sub-tenon block, was employed in some cases and reduced postoperative pain. Similar results were found in a study for pediatric enucleation surgeries.8 Most children were scheduled for repeat surgery within a span of 24 h. This often resulted in prolonged fasting due to uncertainty of the timing of the second procedure. These children usually became restless, anxious, and difficult to control. Hence, care should be taken to continue intravenous or oral clear fluids and initiate feeding as soon as possible. Opioids and nitrous oxide use should be minimized to prevent nausea/vomiting, and prophylactic antiemetics should be administered. Muscle relaxants should be avoided whenever possible to prevent postoperative residual neuromuscular blockade. An awake patient with a patent airway should always be ensured before shifting to the recovery room. Our retrospective analysis provides an early and vital insight into an anesthetist's challenges during brachytherapy for retinoblastoma. Experienced staff, meticulous planning, careful use of drugs, airway devices, interventions, and monitoring are mandatory for a safe outcome. Anxiety, postoperative pain, prolonged fasting, and isolation times are significant concerns that need a multimodal approach. Future studies can be planned to find the most effective interventions in this population. Arshad Ayub: This author helped with the concept and design, wrote the first draft, and approved the final manuscript. Anju Gupta: The author helped with the concept and design, wrote the draft, and approved the final version. Neiwete Lomi: This author helped with data collection, literature search, and manuscript preparation and approved the final manuscript. Renu Sinha: This author helped with data collection and literature search. Bhawna Chawla: This author helped with the study design data collection and approved the final version. I thank all the children and their parents for their time and consent to participate and share their personal information. None. None. Ethical approval taken from the Ethics committee AIIMS Delhi. The data that support the findings of this study are available from the corresponding author upon reasonable request.