Safety Issues and Myths Ophthalmic Anesthesia in the Contemporary ASC

1
Safety Issues and Myths Ophthalmic Anesthesia in
the Contemporary ASC

• Lawrence Rabinowitz, MD, MBA
• Director of Anesthesia Mackool Eye Institute,
  River Drive Surgery Center
• Clinical Assistant Professor CardioThoracic
  Anesthesiology NYU School of Medicine

2
Ask Why

• Pre-op testing
• NPO
• Anticoagulants
• 10 Neosynephrine
• ICDs (implantable cardioverter/defibrillators)
• Stretchers
• IV Access
• Topical

3
Preoperative Evaluation

• Careful History and Physical (not written by the
  surgeon)
• Any laboratory tests indicated by the HP and the
  severity of the surgery (Class A, B, C)
• The Value of Routine Preoperative Medical Testing
  Before Cataract Surgery NEJM 2000342168-75
  Schein, Wilmer Eye Institute, Johns Hopkins
  University
• More Preoperative Assessment by Physicians and
  Less by Laboratory Tests NEJM 2000342204-5
  Roizen, University of Chicago
• Preoperative laboratory testing necessary or
  overkill? Can J Anesth 2004 516 Roizen
• Cataracts
• Trabs, Valves, Transplants (PK, DSEAK) or Retina
  (Retained lens material vs. buckle with membrane
  peel and gas fluid exchange)

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Preoperative Instructions, NPO

• Take all your meds in the morning
• Have a light breakfast and lunch on the day of
  surgery
• Especially important for diabetics, eat and take
  your insulin
• Risk of aspiration only exists if you remove a
  patients gag reflex
• Over 250,000 cases in the last 23 years without a
  single case of aspiration

5
Preoperative Instructions, Meds

• Take all your meds in the morning
• We do not hold ASA, clopidogrel (plavix),
  coumadin
• Presently do 25,000 cases per year at least
  15,000 with a block and rising
• One case cancelled in the last 5 years for
  significant peribulbar hemorrhage, not requiring
  orbital decompression
• Risks of stopping anticoagulation
• Late Thrombosis of Drug-eluting Stents Presenting
  in the Perioperative Period Anesthesiology 2007
  1061057-9, de Souza, University of Virginia
• Current ACC/AHA recommendations are 1 year of
  dual antiplatelet therapy for DES

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Preoperative Drops

• Neosynephrine 10 contains 100mg of phenylephrine
  per ml
• One gtt is approximately 1/15th of one ml or at
  least 6mg of phenylephrine
• In cardiac surgery I give 100 ucg IV (1/60th of
  one gtt of 10) for hypotension, septic patients
  on phenylephrine drips get 100ucg to 400 ucg per
  minute

7
Normal LV and Mitral Function
8
Severe Hypertension
9
Hemodynamic Stability

• Heart Rate Control, Aggressive
• ACC/AHA 2006 Guideline Update on PeriOperative
  Cardiovascular Evaluation for NonCardiac Surgery
  Focused Update on Perioperative B-Blocker
  Therapy, Anesthesia and Analgesia Volume 104, No.
  1, January 2007, Fleisher
• Labetalol (Normodyne)
• Metoprolol (Lopressor)
• Esmolol (Brevibloc)
• ICDs
• Consensus from ACC would be to turn off the ICD
• We have a separate informed consent explaining we
  believe it is safer to leave the ICD on and have
  done several thousand without having one
  discharge

10
IV Access

• Considered the standard of care
• Allows you to respond to the needs of
• Patient
• anxiety, hypertension, tachycardia, arrhythmia
• Surgeon
• lack of patient cooperation
• The patients who will tolerate the procedure
  without IV meds would certainly have had no
  problem with getting an IV, managing expectations
  is key
• If you have a problem, an ophthalmologist will
  not carry standing as an expert in anesthesiology
  in a court of law
• You will probably have issues being paid in the
  future if you dont place an IV

11
Stretchers

• Dramatically less comfortable than Lumex chairs
• Much harder to push a stretcher than walk a
  patient or push a Lumex chair
• Takes time to get them in the proper position in
  the OR
• Our conclusion for eye surgery no faster, much
  less comfortable, more work, much more expensive

12
Stable IOP

• Topical
• Full function of the lids allows for possibility
  of significant increases in IOP, especially if
  the case is complicated and goes on much longer
  than anticipated
• Block
• Diminished muscle strength of orbicularis
  generally provides for stable IOP but is not a
  guarantee

13
Hypothesis, Vitrectomy Rates

• Base rate of vitrectomy was 1.5 with block and
  it increased to 2.25 with topical (50 increase
  in vitrectomy rate)
• Test that hypothesis with 90 power at an alpha
  value of .05
• Sample size (N) necessary to demonstrate this
  difference is 6872 cases in each arm, topical and
  block, or 13,744
• Rollin Brant rollin_at_stat.ubc.ca

• Base rate of vitrectomy was 2.0 with block and
  it increased to 3.0 with topical (50 increase
  in vitrectomy rates)
• Test that hypothesis with 80 power at an alpha
  of .05
• Sample size (N) necessary to demonstrate this
  difference is 3826 cases in each arm, topical and
  block, or 7652
• Rollin Brant rollin_at_stat.ubc.ca

14
References

• Preop Testing
• The Value of Routine Preoperative Medical Testing
  Before Cataract Surgery NEJM 2000342168-75
  Schein, Wilmer Eye Institute, Johns Hopkins
  University
• More Preoperative Assessment by Physicians and
  Less by Laboratory Tests NEJM 2000342204-5
  Roizen, University of Chicago
• Preoperative laboratory testing necessary or
  overkill? Can J Anesth 2004 516 Roizen
• Anticoagulation
• Late Thrombosis of Drug-eluting Stents Presenting
  in the Perioperative Period Anesthesiology 2007
  1061057-9, de Souza, University of Virginia

15
References

• 10 Neosynephrine
• New York State Guidelines on the Topical Use of
  Phenylephrine in the Operating Room,
  Anesthesiology Volume 92 (3) March 2000 pp
  859-864, Groudine
• Hypertension and Pulmonary Edema Associated with
  Sub conj Phenylephrine in a 2 mo old Child during
  Cataract Extraction, Anesthesiology Vol 88 (5)
  May 1998 p 1394-96, Greher
• Adverse systemic effects from pledgets of topical
  ocular phenylephrine 10, American Journal of
  Ophthalmology 2002 Oct134 (4) 624-5,
  Fraunfelder
• Heart Rate Control
• ACC/AHA 2006 Guideline Update on PeriOperative
  Cardiovascular Evaluation for NonCardiac Surgery
  Focused Update on Perioperative B-Blocker
  Therapy, Anesthesia and Analgesia Volume 104, No.
  1, January 2007, Fleisher