Peribulbar block by lacal anesthesia

What is peribulbar block?
peribulbar block is use to obtain Anesthesia and akinesia of the eye by injecting a local Anesthesia  around the muscle cone.

Akinesia of globe

Anesthetic solution for givig block
1.Lidocain hydrocloride.
2.Bupivacain.
3Hyaluronidase.

Lidocain hydrocloride : Bupivacain +Hyaluronidase = 5:3
Use of pactice, Lidocain Hydrocloride:Bupivacain+ Hyaluronidase =5:1
So,50ml Lidocain hydrocloride 2%+10ml Bupivacain +1500IU Hyaluronidase.
use of block.

Quantity of Anesthetic solution :
For peribulbar block :6-8 cc.

Use of needle of peribulbar block:
1inch or 23 G steel needle or 1/2 inch 26G needle.

Techniques of peribulbar block:
Inferior injection is gigen at the junction of the outer one third & inner two third of the lowe orbital rim.

Or, Superior injection is given usually nassally just above the medial canthus the superior injection may be avoided till the time the inferior injection take effect to judge the necessity for the additional injection.

Or, If good akinesia is attained by the inferior there is no needed for the superior injection. Gently press on the lower lid between the orbital margin and the globe to feel the inferior orbital notch and with the other hand progressively injection 5ml of the anesthetic solution starting solution just under the skin, progressively to just behind the quator of the globe.

peribulbar block procedure 

Guiding  of the needle :
The needle should be slowly advanced, stopping immediately. If there is either a tugging movement of the globe which may indicate sangging of the needle on sclera or an extra ocular muscle.

or, Some ask the patient to look up and down to ensure that the globe has not been impaled other believe that this could cause adjecnt orbital structure to be lacerated over the needle tip.

or,If there is either severe pain or persiatance to injection either of which can indicate injetion into the globe.

Peribulbar block procedure end

Complication of peribulbar block:
1.Venous orbital haemorrhage.
2.Anterior orbital haemorrhage.
3.Allergic reaction.
4.Opthalmophegia direct damage of the EOM(Extra -ocular muscle)
5.Globe perforation.
6.Central sperade of anesthetic life the retina.
7.Optic nerve damage.

Globe perforation:
1.This complication is very rare in experienced hand.

2.More common with the longer eye specifically with stapiloma.

3.If the needle cantes of the sclera, the cornea first moves towards the needle and then suddenly away from it as the needle presses through the sclera.

4.If optain painful, but not always noticed at the time.

5.Surgon might notice the abcence of the red reflex an excessively soft eye or excessively hard eye with coudy cornea if LA has been injected inside the eye.

6.Sometimes the procedure is placid and also the telltale retinal appnrence could also be detected years in a while routine fundoscopy.

7.Rarely enough anaesthesia canbe injected within the attention to cause ocular explosion. this needs IOP of 2800 metric linear unit of hg.
8.Even with immediate recognition the visual prognosis for suchan eye is poor.

How to avoid perforation?
Subtenons block can be used an alternative to peribulbar block as incidence of perforation is minimal.

High risk pregnancy signs and symptoms

High risk pregnancy:
High risk pregnancy is defined as one which is complicated by factor or factors that adversely affect the pregnancy outcome -maternal or perinatal or both.

Signs of high risk pregnancy.
1.Swelling of the feet.
2.Blurring of vision.
3.Per-vaginal discharge.
4.Per-vaginal bleeding.
5.Convulsion.

Criteria of high risk pregnancy:
1.During pregnancy.

Elderly primi(>30years of age)

Short stature primi(<140cm)

Threatened abortion & antepartum haemorrhage.

Malpresentation.

Pre-eclampsia & Eclampsia.

Anaemia.

Elderly grand multiparas.

Twins & polyhydramnios.

Manual removal of placenta.

Prolong labour.

History of previous caesarean section & instumental delivery.

Pregnancy associated with mdical disease.

2.During labour.

Pre mature rupture of membranes.

Prolong labour.

Head,feet and cord prolapse.

Post -partum haemorrhage.

Puerperal haemorrhage.

Select cases for hospital  delivery.
High risk cases: The cases are assessed at the initial antenatal examination, preferably in the 1st trimester of pretnancy.
Family history:

Socio-economic condiction:Poor socio-economic status has a high incidence of anaemia,IUG& preterm labour.

Family history of a diabetes mellitus,hypertension,multiple pregnancy, congenital anomalis.                                       Obstetric history:

Two or more previous spontaneous abortion.

Previous still birth, neonata,death death or birth of babies with congenital anomaly.

Previous preterm or small for date or big baby.

Grand multiparity.

Previous caesarean section or hysterectomy.

Pre-eclampsia or eclampsia.

Third stage abnormalitis.

History of medical disease:

Pulmonary disease.

Viral hepatitis.

Cardiac disease.

Renal disease.

Throid disease.

Epilepsy.

Post surgical history:

Myomectomy.

Repair of vesico-vaginal history.

Repair of complete perineal tear.

Repair of stress incontinence.

General examination:

Hight:<150cm.

Weight:Overweight or underweight both are risk factor.

High blood pressure.

Anaemia.

Cardiac or pulmonary disease.

Pre abdominal examination :

Genital prolapse.

Dialatation of the cervix.

Assiociated tuomer.

Follow up:
1.Pre-eclampsia.
2.Anaemia.
3.High-fever.
4.Pyelonepritis.
5.Haemorrhage.
6.DM.
7.Lage uterus.
8.Lac of uterine growth.
9.Post maturity.
10.Twin pregnancy.

Anaemia symptoms signs and treatment

Anaemia:
It is a clinical condiction characterized by pale coloration of skin,mucus membrane, & sclera due to qualitative and quantitative deficiency of HB% below the level at the normal range in the pheripheral blood for the age and sex of the individual.

Classification of anaemia:
A.Morphological classification.
B.Aetiological classification.
C.Clinical classification.

Morphological classification:
 a.Microcytic hypochromic anaemia.
    1.Iron deficiency anaemia.
    2.Thalassaemia.
    3.Anaemia of chronic disease.
 b.Normocytic normochromic anaemia.
    1.Haemorrhagic anaemia.
    2.Haemolytic anaemia.
    2.Aplestic anaemia.
    3.Renal failure.
 c.Macrocytic anaemia.
    1.Megaloblastic anaemia.
    2.Pernicious anaemia.

Aetiological classifiacation:
    1.Iron deficiency anaemia.
    2.Haemorrhagic anaemia.
    3.Haemolytic anaemia.
    4.Aplestic anaemia.
    5.Anaemia of chronic disease.

Clinical classification:
    1.Mild:12-9 gm/dl.
    2.Moderate:9-6 gm/dl.
    3.Severe:<= 6 gm/dl.

Site of anaemia:
    1.Lower palpable conjuntiva.
    2.Dorsal of the tunge.
    3.Buccal mucus membrane.
    4.Palm of the hand.
    5.Nail bed.
    6.Sole of the foot.
    7.Whole skin.

Normal level of Hb:
    1.Male:13-18 gm/dl.
    2.Female:11.5-16.5 gm/dl.
    3.Children:16-19 gm/dl.
    4.At birth:18-20 gm/dl.

Management of anaemia:
  A.Clinical feature:
   Symptom:
      1.Weakness.
      2.Tiredness.
      3.Lassitude.
      4.Fatigu.
      5.Palpitation.
      6.Anorexia.
      7.Headach.
      9.Dizziness.
    10.Dimness of vision.
  Sign:
      1.pallor-lower palpabral
         conjuntiva.
      2.Thchycardia.
      3.Cardiac dilation.
      4.Systemic flow murmur.

  B.Investigation:
      1.CBC with ESR.

 C.Treatment:
      1.Blood transfusion if needed.
      2.Treatment according to cause.

antenatal care definition and objectives

Antenatal care: Systemic supervision of a woman during pregnency which should be of a regular and periodic nature in accordance with the principal laid down one or more frequently according to the need of the individual is called antenatal care.

Aim of antenatal care:
1.To screen the high risk cases.
2.To prevent and to detect and treat at the earlist any complication.
3.To ensure continued medical survillance and prophylaxis.
4.To educate the mother about the physiology of pregnancy and labour by demostration charts and diagrams so that fear is removed and phychology is improved.
5.To discuss with the couple about the place, time and mode of delivery, provisionally and care of the new born.
6.To motivate the couple about to the need of family planning.

Objective of antenatal care:
The object is to enture a normal pregnancy with the delivery of the healthy mother.The criteria of the normal pregnancy are.
1.Delivery of a single baby in good condiction at term.
2.Fetal weight of 2.5 kg or more.
3.With the matarnal complications.

Importance of antenatal care:
1.To screen out high risk cases.
2.Detection of high risk factors.
3.Regular supervision of pregnancy.
4.To mike the patient realize that the pregnancy is a physiological process & to give phycological support.

Mention the WHO recommendation of antenatal visit.
1st visit(by 16 weeks):

Anaemia,syphilis,medical and obstetric risk factor.

Individualize birth plan and health education.

2nd visit(between 24-28 weeks)

Syphilis,fundal height.

3rd visit.(32th weeks)

Symphisis fundal height.

Pre eclampsia.

Further develop individualized birth plan.

4th visit:(36 weeks)

Indentify fetal lie.

Update the individualize birth plan.

Mention the investigation done in first antenatal visit.
History taking:

Particular of the patient.

Name.

Date of first examination.

Address.

Age.

Gravida.

Duration of the marriage.

Religion.

Occupation.

Occupation of the husband.

Period of gastation.

Menstural history:

Cycle.

Duration.

Amount of blood floow.

LNMP.

EDD.

Family history:

Family history of the hypertension.

DM.

Tuberculosis.

Personal history:

Habits.

Contraceptive history.

Clinical examination:
 General examination:

Body buid.

Nutritional status.

Height.

Weight.

Pulse.

BP.

Temperature.

Anaemia.

Jaundice.

Oedema.

Dehudration.

Per abdominal examination:

Inspection:Shape of the abdomen,scar marks.

Palpation:Hight of the uterus.fetal movement.

Four grips:Fundal grip two lateral grip,pelvic grip.

Auscultation:

Fetal heart rate.

Other examination:

Cardio vascular examination.

Respiratory examination.

Per-vaginal examination:

To exclude the pwlvic pathology.

To diagonase the pregnancy.

Investigation:

Blood:Hb%,ABO groping&Rh typing,VBRL.

RBS.

Urine R/M/E.

USG of P/P.

Antenatal advice:
1.Diatary advice-The diet during pregnancy should adiquet to provide.

Good maternal health.

Optimism fetal growth.

Successfully lactation.

2.The pregnancy diet should be diet,nutrition,protin,minarals,vitamins.
3. The diet should consist and addition to the principal food at least milk,green vagitables,fruits.

Antenatal hygine:
1.Rest and sleep.
 2.Bowel :Constipation is common -it may cause backach and abdominal discomfort. regular bowel may be faciliated by regulation of diet taking plenty of fluids, vegitables and milk.
3.Bathing:The patient should be take daily birth but be careful against slipping in the birthroom due to imbalance.
4.Coitus:

Generally coitus ia not reatricted during pregnancy.

Release of prostaglandins and oxytocin coitus may cause utrine cotractions.

Women with increasing risk of miscarriage or preterm labour should be avoid coitus.

Immunization: TT immunization:

1st dose :At 5th month.

2nd dose:At 7th month.

General advice:
1.Advice to attend for antenatal check-up positively on the schedule date of visit.
2.The patient should be instructed to report as early as posible if some serious symptom arise such as intanse headach,per vaginal bledding discharge absent,less fetal movement,vomiting,scanty micturation.etc.

She advise come to hospital for considaration of admission in the following circumstances.
1.painful uterine contraction.
2.Sudden gush of watery fluid per-vagina suggestive of premature rupture of the mambrane.
3.Active vaginal bledding, however slight it may be.