Misadventures of Eye Surgery DAVID LARSEN MD
Disclosures Employed by Oregon Health and Science University Director of Anesthesia Services at Casey Eye Institute A large portion of my income is based on utilization of anesthesia services for eye surgery
This Audience Today:
Objectives: 1) List at least 3 differences between Ophthalmic Surgery and other outpatient surgical procedures pertaining to patient safety 2) List 3 goals of how to prepare should your surgery center choose to not utilize an anesthesia provider 3) List 3 ways to minimize a patients anxiety over cataract surgery without use of sedatives
Order of presentation: Case Presentations Why makes Ophthalmic Surgery unique? Training requirements What does the UK do? What do you feel comfortable doing? Who makes the decision? Suggestions for practice
Case Presentation 40 year old female for routine cataract No anxiety pre-op No health issues No “red flags” Did not want any relaxation medication for the procedure “I’ll be fine” Topical anesthetic drops liberally used
Case Presentation No issues until just after the capsulorhexis Patient states “STOP!” “Don’t touch me !” “If you touch me I will sue you !” “Don’t give me anything!” “I will sue you !” What do you do?
Case Presentation 65 y/o female for right eye lens repositioning, possible lens exchange Pre-op BP 138/67 with HR of 60 Healthy patient, but did have a prior right sided Bells Palsy which resolved 2 years previous. Planned retrobulbar block for case Patient sedated with 2mg Versed and 50mcg Fentanyl Block administered BP now 240/112 with HR 112 Patient slurring speech with clear right face weakness/loss of tone What do you do?
What makes Ophthalmic surgery unique? Very small movements are detrimental Changes in Blood Pressure can effect outcomes Post-operative nausea can be detrimental – not just a nuisance You get one shot to do it with the best outcomes Movements/pressure on the eye can cause cardiac changes Patients are anxious over their eye more than other body parts/areas Patient positioning can be more straining on patient Airway, back pain, benign positional vertigo, obese patients, elderly, heart failure Ophthalmologist cannot see what is happening – they are looking into a scope, not at the patient
Training requirements Cardiologists: electrophysiology studies, cardioversions, transtracheal echocardiography, pacemaker placement Gastroenterologists: upper endoscopy, colonoscopies Internists: tapping of ascites, plueral effusion draining, central line placements Family practice: toe nail excisions, sebaceous cysts, mole biopsies OB/GYN: LEEP procedures, biopsies ER physicians – a lot of above procedures Ophthalmologists – cataracts, pterygiums, chalazion
Training requirements Sedation training for acute procedural pain: Cardiologists: 18 months Gastroenterologists: 25-29 months Internists: 5-9 months Family Practice: 6 months OB/GYN: zero ER Physicians: 15 months Ophthalmology: 1 month
UK Model In: “Local anaesthesia for ophthalmic surgery, Joint guidelines from the Royal College of Anaesthetists and the Royal College of Ophthalmologists February 2012” “All ophthalmic surgery performed should be carried out in a facility which is appropriately equipped and staffed for advanced resuscitation” “Every hospital or unit undertaking ophthalmic surgery should identify one anaesthetist with overall responsibility for the anaesthetic services to the eye department” “record keeping must be comprehensive” “pre - operative assessment…..completed before the patient enters the operating theatre area” “The purpose of the per -operative assessment is to ensure that the patient is fit for the planned procedure” “Any patient requiring special tests may also need an opinion from a doctor”
UK Model “intravenous sedation should only be administered under the direct supervision of an anaesthetist , whose sole responsibility is to that” “A suitably trained individual must have responsibility for monitoring the patient throughout anaesthesia and surgery” “All theatre personnel should participate in regular Basic Life Support training” “Where the unit is free - standing…there should be at least one person with Advanced Life Support or equivalent” No mention of topical only without any sedation and requirements
What do you feel comfortable doing? In your institution: Who is ACLS certified? Who monitors the patient? Who fills out monitoring record? Who does a full pre-operative assessment prior to beginning procedure? Who is trained to handle unplanned emergencies? Who is the person who looks over lab tests and situational issues? Who orders the sedative, who administers the sedative? Would your surgeon feel comfortable doing all the above?
What can happen? When asked “What misadventures other than those related to sedation/anesthesia have you seen in cataract surgery?” Vomiting Acute Congestive Heart Failure Complete panic attack from previously non-anxious patient Claustrophobia from patient who previously had no such knowledge or thought to be claustrophobic Complete vagal episode needing airway intervention Uncontrolled secretions requiring active suctioning Sleep apnea (yes without sedatives) requiring airway manipulation Hypertensive crisis causing choroidal hemorrhage Myocardial infarction brought on by anxiety over procedure Questionable Takosubos cardiomyopathy Questionable thyroid storm Who manages potential issues?
Anesthesia and MAC Anesthesia team provides or medically directs: Diagnosis and treatment of clinical problems that occur during the procedure Support of vital functions Administration of sedatives, analgesics, hypnotics, anesthetic agents or other medications as necessary for patient safety Psychological support and physical comfort Provision of other medical services as needed to complete the procedure safely American Society of Anesthesiologists. Position on Monitored Anesthesia Care. Origin October 21, 1986 updated October 16, 2013
One Ophthalmologists thoughts: “I believe it’s reasonable to perform a straightforward cataract surgery without a CRNA or anesthesiologist present, so long as the following conditions are met……” Strictly medically screen your patients. In clinic and pre-op. Cancel cases where anything does not seem right “crack nursing team” experienced with versed and fentanyl Surgeon has resuscitative training. All staff have taken BLS and ACLS. Hospital nearby willing to accept your patients “the most important question is whether you’re comfortable with your emergency skills.” Review of Ophthalmology; “Cataract Surgery: Is an Anesthesiologist Necessary?” March 2009
Ophthalmologist or Anesthesia Decision Pre-operative insulin, what dose, what time Blood Pressure medications, what dose, what time Parkinsons medications Post-op pain opioid? Is this patient medically ok to go home? Who will hold still without sedative, if not, how much can I give? How to handle paradoxical reaction to versed, fentanyl, ketamine etc “Deliberate patient selection and judicious choice of suitable anesthesia technique is requisite to determine the optimal anesthesia care prescription” Anesthesiology; “Key Components of Risk Associated with Ophthalmic Anesthesia” Gayer, Steven MD, MBA Oct 2006 Vol 105 p859
Minimizing need for sedation Lower anxiety of patient Short video on what to expect during cataract surgery Discussing lights, shadows, movement, eye drops, hearing music etc. Pre-operative visit – showing a positive attitude about the surgery and taking time to discuss issues the patient may face. Counseling to the patient about what to expect. Remember: topical proparacaine only lasts up to 10-15 minutes – re-dose if needed Have a calm pre-operative and intra-operative environment – create a positive atmosphere Watch vernacular “visual experience frightening” should be turned to “pretty colors” or “light - show” Eye; “Patients’ expectation and experience of visual sensations during phacoemulsification under topical anaesthesia ” Sep2007 Vol 21 p1162 -1167 Dermatologic Surgery; “Anesthesia for Office - Based Oculoplastic Surgery” July 2005 Vol 31 p766-770 Eye Science; “Application of Preoperative Visits during the Perioperative Period of Ophthalmic Surgery” June 2015 Vol 30 p56 -59 British Journal of Ophthalmology; “Randomized controlled trial of preoperative information to improve satisfaction with cataract surgery” Jan 2005 Vol 89; p10 -13
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