Anesthetic Management Guidelines for Strabismus Surgery in Adolescents

Muscle Relaxation

Rocuronium (0.6–0.9 mg/kg) or atracurium/cisatracurium should be used instead of succinylcholine because they carry a lower risk of anaphylaxis. 1, 2

Full reversal of neuromuscular blockade with sugammadex is recommended, as it shortens the time to achieve a train‑of‑four ratio of 0.9 compared with neostigmine. 3, 4

Current evidence does not demonstrate a clear advantage of awake versus deep extubation in uncomplicated strabismus surgery; the choice should be individualized based on patient‑specific risks. 5, 3, 4

Maintain age‑appropriate tidal volume (5–8 mL/kg) and respiratory rate (12–25 breaths/min). 5, 3
Verify complete neuromuscular recovery (TOF ratio ≥ 0.9) before extubation. 3
Ensure SpO₂ ≥ 95 % on FiO₂ ≤ 50 %. 5
Obtain a reliable motor response to commands. 5
Observe for purposeful movements such as grimacing, eye opening, or purposeful limb motion. 5, 3
Awake extubation protects against aspiration and airway obstruction but increases the likelihood of cough and agitation, which may precipitate surgical site bleeding. 5, 3, 6

Effective spontaneous breathing with tidal volume ≥ 5 mL/kg and age‑appropriate respiratory rate. 5, 3, 4
Small, centrally located pupils on examination. 5, 3
Maintain at least 1 MAC of volatile anesthetic at the moment of extubation. 5, 3, 4
Consider placing the patient in the lateral decubitus position to reduce the risk of laryngospasm and desaturation. 5, 3
Deep extubation reduces cough and emergence agitation but raises the risk of postoperative obstructive apnea. 6

Choose awake extubation when the adolescent can reliably follow commands, ensuring intact laryngeal reflexes. 5, 3
Opt for deep extubation if significant emergence delirium is anticipated despite dexmedetomidine premedication, or if coughing would pose a high risk for postoperative bleeding. 5, 3, 6

Closely observe for laryngospasm, bronchospasm, and desaturation during the immediate postoperative period. 5, 3, 6

Minimize opioid administration because opioids increase the incidence of postoperative nausea and vomiting and may cause respiratory depression. 7

Failure to achieve a TOF ratio of 0.9 before extubation is associated with postoperative respiratory complications; verification of adequate reversal is mandatory. 3, 4

High opioid consumption worsens postoperative nausea and vomiting and can delay discharge from the recovery area. 7