Misadventures of Eye Surgery DAVID LARSEN MD Disclosures Employed - - PowerPoint PPT Presentation
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
DAVID LARSEN MD
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
1) List at least 3 differences between Ophthalmic Surgery and other
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
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
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
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?
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
What do you do?
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
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
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
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
the eye department”
“record keeping must be comprehensive” “pre-operative assessment…..completed before the patient enters the
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”
“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
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?
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 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
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
“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
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
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
“In an age of sedation dentistry, increasing patient education
resources, and greater anesthesia presence throughout the hospital, will anesthesia care for most ophthalmologic surgery patients be eliminated?”
Anesthesiology; “Sedation and Anesthesia Care for Ophthalmologic
Surgery during Local/Regional Anesthesia”; September 2007 Vol 107 502-508
“Although application of topical anaesthesia is simple, it is not a fail-
proof mechanism. Many situations mandate the immediate availability of personnel adept in sedation, anaesthesia, and airway management.”
BJA; “Role of the anaesthetist during cataract surgery under local
anaesthesia” Vol 105 issue 2 August 2010 p235
Treat patient, not their insurance If patient will do well without meds, great for them - do it If patient won’t do well without meds, then arrange for a
suitable site and personnel to do the surgery
Many patients do very well without any sedation. Many do not. It’s incumbent on each of us to do what’s right for the patient –
that may be no sedatives, it may be a change in venue
Must have plan in place with patients knowledge in case of
having a misadventure
For myself: I’m happy to go without anesthesia personnel for my
cataract surgery. For my mother: you better have someone there who knows how to treat issues.
“I will sue you” lady
Demanded husband be brought into OR with her or
“I will sue you”
So we brought husband into OR with her. He held her hand and only then
she allowed us to give her some relaxant.
Retrobulbar block lady with extreme high blood pressure just after
block:
Right facial droop with floppy arms and legs Slurred speech Surgeon deferred to anesthesia judgment OR nurse (former ICU) demanded patient go to ER for stroke Patient given labetalol and time – re-evaluated every 3 minutes Slowly over 1.5 hours patient fully recovered – case was rescheduled to
another day