Anesthesiologists role in ophtalmic surgery with special emphasis on

day/office surgeryIl ruolo dell’anestesista nella chirurgia oftalmologica

con speciale riguardo alla day surgery

Dott.Claudio MelloniLibero professionista

Spec.in Anestesia e Rianimazione

Anesthesiologist role and services :

• Safety:– screening of patients– Administration of anesthesia– Monitoring of vital signs – Prevention of complications– Treatment of complications– Safe discharge

• Cooperation• Administrative• Financial• helping to develop and review policies• equipment-purchasing • drug formulary advice.

Value added services

• helping to develop and review policies• ensuring earlier discharges • offering equipment-purchasing • drug formulary advice

For O.R.:

•performing anesthesia/analgesia/resuscitation...............

Anesthesiologist added value....

• make sure the surgery schedule starts on time; • decrease turnover time; • decrease cancellations by using pre-op phone calls

and questionnaires; • spearhead proper anti-PONV efforts, including pre-op

risk assessments and interventions;• use such PONV-sparing anesthesia techniques • provide pain prophylaxis,• administer antibiotics in a timely manner• employ anti-venous embolism strategies.

Beyond O.R.• Equipment purchases,evaluation,maintenance :a separate contribution?• •Drug formulary:streamline the number of medication choices in a common sense and cost-effective

manner. For example, is there really a need for 5 different non-depolarizing muscle relaxants and 5 different narcotics?

• Agree on practices /surgical load • Participating in lectures and seminars in the surgeons' offices takes some of the fear out of scheduling

surgery and can put patients and families at ease when they see another familiar face on the day of surgery. It's a great educational and PR opportunity.

• Sit on committees. Your anesthesia team should be eager participants on your committees, even if they are not owners or partners. This promotes a collaborative team feeling, and their input will be clinically vital and important to the overall health and strategic planning for the facility.

• Help formulate policies. Review and revision of policies and procedures is a critical area that necessitates anesthesia department participation, particularly when there is an impending certification inspection.

• Explain anesthesia billing. Your anesthesia team should designate someone — beyond billing personnel — who is adept and comfortable handling potentially tricky discussions about the bill for anesthesia services. This person must understand the subtleties and unique qualities of anesthesia billing, and be flexible and patient when trying to explain and resolve billing issues.

Anaesthetic Requirement

• Safety• Akinesia• Analgesia• Minimal bleeding• Avoidance or obtundation of oculocardiac reflex• Prevention of rise in I.O.P• Awareness of drug interaction• Smooth emergence (no vomiting, coughing, retching)• Pupil should be dilated for IO surgery (except• glaucoma)• Anaesthesia for Eye Surgery

TOPICs:discussion• Preop testing• Monitoring• Arrythmias detection• Accessories• Discharge• Some cases...• Patient evaluation:– Fitness ....Anticoag...........

• phenylephrine

PREOP TESTING

Preop .Lab?

• Most cataracts are performed on older individuals with correspondingly high systemic and ocular comorbidities.

• routine preoperative medical testing will detect medical conditions?

• it is questionable whether these conditions should preclude individuals from cataract surgery or change their perioperative management.

Br J Anaesth. 2013 Jun;110(6):926-39. Effectiveness of non-cardiac preoperative testing in non-cardiac elective surgery: a systematic review.

Johansson T, Fritsch G, Flamm M, Hansbauer B, Bachofner N, Mann E, Bock M, Sönnichsen AC.

• Elective surgery is usually preceded by preoperative diagnostics to minimize risk. • The results are assumed to elicit preventive measures or even cancellation of surgery.• Moreover, physicians perform preoperative tests as a baseline to detect subsequent changes. • This systematic review aims to explore whether preoperative testing leads to changes in management or reduces perioperative

mortality or morbidity in unselected patients undergoing elective, non-cardiac surgery. • We systematically seardatabases from January 2001 to February 2011 for studies investigating the relationship between

preoperative diagnostics and perioperative outcome.• methodology was based on the manual of the Ludwig Boltzmann Institute for Health Technology Assessment, the Scottish

Intercollegiate Guidelines Network (SIGN) handbook, and the PRISMA statement for reporting systematic reviews.• 101/25 281 publications retrieved met our inclusion criteria. Three test grid studies used a randomized controlled design and 98

studies used an observational design.

• The test grid studies show that in cataract surgery and ambulatory surgery, there are no significant differences between patients with indicated preoperative testing and no testing regarding perioperative outcome. The observational studies do not provide valid evidence that preoperative testing is beneficial in healthy adults undergoing non-cardiac surgery. There is no evidence derived from high-quality studies that supports routine preoperative testing in healthy adults undergoing non-cardiac surgery. Testing according to pathological findings in a patient's medical history or physical examination seems justified, although the evidence is scarce. High-quality studies, especially large randomized controlled trials, are needed to explore the effectiveness of indicated preoperative testin

Am Fam Physician. 2013 Mar 15;87(6):414-8.Preoperative testing before noncardiac surgery: guidelines and

recommendations.Feely MA, Collins CS, Daniels PR, Kebede EB, Jatoi A, Mauck KF.

• Preoperative testing (e.g., chest radiography, electrocardiography, laboratory testing, urinalysis) is often performed before surgical procedures. These investigations can be helpful to stratify risk, direct anesthetic choices, and guide postoperative management, but often are obtained because of protocol rather than medical necessity. The decision to order preoperative tests should be guided by the patient's clinical history, comorbidities, and physical examination findings. Patients with signs or symptoms of active cardiovascular disease should be evaluated with appropriate testing, regardless of their preoperative status. Electrocardiography is recommended for patients undergoing high-risk surgery and those undergoing intermediate-risk surgery who have additional risk factors. Patients undergoing low-risk surgery do not require electrocardiography. Chest radiography is reasonable for patients at risk of postoperative pulmonary complications if the results would change perioperative management. Preoperative urinalysis is recommended for patients undergoing invasive urologic procedures and those undergoing implantation of foreign material. Electrolyte and creatinine testing should be performed in patients with underlying chronic disease and those taking medications that predispose them to electrolyte abnormalities or renal failure. Random glucose testing should be performed in patients at high risk of undiagnosed diabetes mellitus. In patients with diagnosed diabetes, A1C testing is recommended only if the result would change perioperative management. A complete blood count is indicated for patients with diseases that increase the risk of anemia or patients in whom significant perioperative blood loss is anticipated. Coagulation studies are reserved for patients with a history of bleeding or medical conditions that predispose them to bleeding, and for

those taking anticoagulants. Patients in their usual state of health who are undergoing cataract surgery do not require preoperative testing.

Anesthesiology. 2013 May;118(5):1038-45. Global health implications of preanesthesia medical examination for ophthalmic surgery.

Phillips MB, Bendel RE, Crook JE, Diehl NN.

• Author information

• Abstract• BACKGROUND:• Preanesthesia medical examination is a common procedure performed before ophthalmic surgery. The frequency and characteristics of new medical issues and unstable medical conditions

revealed by ophthalmic preanesthesia medical examination are unknown. We conducted a prospective observational study to estimate the proportion of patients with new medical issues and unstable medical conditions discovered during ophthalmic preanesthesia medical examination. Secondary aims were to characterize abnormal findings and assess surgical delay and adverse perioperative events, in relation to findings.

• METHODS:• Patients having preanesthesia medical examination, before ophthalmic surgery, were enrolled over a period of 2 years. A review was conducted of historical, physical examination, and test

findings from the preanesthesia medical examination.• RESULTS:• From review of medical records of 530 patients, 100 patients (19%; 95% CI, 16-23%) were reported by providers to have abnormal conditions requiring further medical evaluation. Of these, 12

(12%) had surgery delayed. Retrospective review of examination results identified an additional 114 patients with abnormal findings for a total of 214 (40%; 95% CI, 36-45%) patients. Among the 214 patients, primary findings were cardiovascular (139, 26%), endocrine (26, 5%), and renal (24, 5%). Complications occurred in 49 (9%; 95% CI, 7-12%) patients within 1 month of surgery.

• CONCLUSIONS:

• Ophthalmic preanesthesia medical examination frequently detects new medical issues or unstable existing conditions, which do not typically alter conduct of perioperative procedures or outcomes. However, these conditions are relevant to long-term patient health and should be conveyed to primary care physicians for further evaluation

Cochrane Database Syst Rev. 2009.Routine preoperative medical testing for cataract surgery.

Keay L, Lindsley K, Tielsch J, Katz J, Schein O.

OBJECTIVES:• (1) To investigate the evidence for reductions in adverse events through preoperative medical testing, and (2) to estimate the

average cost of performing routine medical testing.• SEARCH STRATEGY:• We searched CENTRAL, MEDLINE, EMBASE and LILACS using no date or language restrictions. We used reference lists and the

Science Citation Index to search for additional studies.• SELECTION CRITERIA:• We included randomized clinical trials in which routine preoperative medical testing was compared to no preoperative or

selective preoperative testing prior to age-related cataract surgery.• DATA COLLECTION AND ANALYSIS:• Two review authors independently assessed abstracts to identify possible trials for inclusion. For each included study, two

review authors independently documented study characteristics, extracted data, and assessed methodological quality.• MAIN RESULTS:• The three randomized clinical trials included in this review reported results for 21,531 total cataract surgeries with 707 total

surgery-associated medical adverse events, including 61 hospitalizations and three deaths. Of the 707 medical adverse events reported, 353 occurred in the pretesting group and 354 occurred in the no testing group. Most events were cardiovascular and occurred during the intraoperative period. Routine preoperative medical testing did not reduce the risk of intraoperative (OR 1.02, 95% CI 0.85 to 1.22) or postoperative medical adverse events (OR 0.96, 95% CI 0.74 to 1.24) when compared to selective or no testing. Cost savings were evaluated in one study which estimated the costs to be 2.55 times higher in those with preoperative medical testing compared to those without preoperative medical testing. There was no difference in cancellation of surgery between those with preoperative medical testing and those with no or limited preoperative testing, reported by two studies.

AUTHORS' CONCLUSIONSThis review has shown that routine pre-operative testing does not increase the safety of cataract surgery. Alternatives to routine preoperative medical testing have been proposed, including self-administered health questionnaires, which could substitute for health provider histories and physical examinations. Such avenues may lead to cost-effective means of identifying those at increased risk of medical adverse events due to cataract surgery. However, despite the rare occurrence, adverse medical events precipitated by cataract surgery remain a concern because of the large number of elderly patients with multiple medical comorbidities who have cataract surgery in various settings. The studies summarized in this review should assist recommendations for the standard of care of cataract surgery, at least in developed settings. Unfortunately, in developing country settings, medical history questionnaires would be useless to screen for risk since few people have ever been to a physician, let alone been diagnosed with any chronic disease

Patient selection and assessment

MONITORING

Datex 1996

Airway trolley

Syringe pumps

Back up monitors ;minilab?Hemocue glucose

Cardiocap and Capnomac

EEG monitoring???

Too deep?

Prese ossigeno:qui foto

Competitive edge

• In an economy that continues to bring decreased caseloads and the potential for reimbursement uncertainty and upheaval, anesthesia groups that can provide value-added staffing flexibility could make or break your bottom line.

• This means more than just avoiding a revolving door of unfamiliar providers that make your surgeons anxious. Your providers must share your strategic goals and understand your corporate and community culture. They must provide anesthesia delivery models that strive to put the right patients in the right facilities at the right time, in order to provide the safest and best outcomes in the most cost-effective manner. If a subsidy or stipend is requested or contracted, then it should be done transparently and properly incentivized.

• It's a scary environment out there for anesthesia professionals and facilities. An attitude of collaboration and cooperation designed to add value to all we do is a recipe for success for ourselves and the patients and communities we serve.

•

standards

•Same standards as per O.R•Continuous anesthetic surveillance.

Requisites • Any unit providing sedation techniques should have the following• readily available :• Suitably trained individual to monitor the patient

– • ECG• • Non-invasive blood pressure monitoring• • Pulse oximetry

• etCO2 …..

• Further requirements include:• • The patient should be sedated on a trolley or operating table that can

be tipped head-down• • Oxygen should be readily available• • Full resuscitation equipment should be available

– Laryngoscope,LMA’s,suction,ventilator,defibrillator etc:drugs(lipids?)…………..• • The staff looking after the patient should be trained and regularly updated

in resuscitation techniques.

Training in CPR/ALS

• Certificates for the anesthesiologist(s) and surgeons!

• Certificates for BLS(D) for nurses• ricertifications needed…………

REBREATHING UNDER DRAPES

Oxygen application by a nasal probe prevents hypoxia but not rebreathing of carbon dioxide in patients undergoing eye surgery under local anaesthesia.

Schlager A, Luger TJ. : Br J Ophthalmol. 2000 Apr;84(4):399-402

New equipment to prevent carbon dioxide rebreathing during eye surgery under retrobulbar anaesthesia.Schlager A, Staud H

Br J Ophthalmol. 1999 Oct;83(10):1131-4

EtCO2 Divided Sampling Cannula with Simultaneous Oxygen Delivery

•Features •Design incorporates a permanent barrier in the facepiece and a dual tubing set.

•Benefits•Allows End Tidal sampling from one nare and oxygen or gaseous analgesia delivery to the other. Delivers accurate, quantitative reading. Eliminates dilution of gases

•Unique, innovative configuration, no modification required. Integrity of the procedure is certain

•Same quantitative readings seen during general anesthesia. Safe, simple, cost-effective monitoring of EtCO2

•Curved, tapered nasal prongs. Facepiece anatomically curved to fit upper lip

•Better anatomical fit for long term use. No irritating flap or ridge

•Soft, lightweight clear material •Does not interfere with patient observation•Full range of sizes available •Versatile. Compatible with all systems and

modalities prescribed

•Dual Port Salter Eyes® •Safety apertures to reduce possible occlusions

•22 mm I.D. X 6 mm O.D. anesthesia circuit oxygen adapter

•Allows easy connection to anesthesia “Y” fitting or other large bore oxygen source

EtCO2 Divided Sampling Cannula with Simultaneous Oxygen Delivery

Oral-Trac® Oral/Nasal EtCO2 Divided Sampling Cannula with Oxygen Delivery

With Unique Oral Sampling TRUNK Accurate End Tidal Sampling with Simultaneous Oxygen Delivery. The Salter Oral-Trac® oral/nasal cannula features dual EtCO2 sampling through both nasal prong and a unique oral sampling trunk. This allows accurate patient monitoring even during spontaneous breathing or with mouth breathers. Simultaneously oxygen can be delivered through a separate tube and nasal prong. A permanent barrier in the facepiece separates the oxygen delivery and EtCO2 sampling pathways to permit an undiluted gas sample. Salter-Eyes®, safety apertures (a Salter exclusive) are incorporated

Cannula brevettata a 2 vie per somministrazione di ossigeno e campionamento della CO2 espirata

setto che separa le due vie

Curva della CO2 espirata(etCO2)

Oral-Trac® Oral/Nasal EtCO2 Divided Sampling Cannula with Oxygen Delivery

Features•Oral/Nasal End Tidal CO2 sampling

•BenefitsDelivers accurate, quantitative waveforms

•Additional oral sampling through TRUNK •Provides more accurate EtCO2 sampling during spontaneous nose or mouth breathing

•Design incorporates a permanent barrier in the facepiece and a dual tubing set

•Allows End Tidal sampling from one naris and TRUNK while oxygen or gaseous analgesia is delivered to the other naris

•Oral sampling TRUNK is adjustable to fit individual patient’s facial contours

•Ensures optimal placement for maximum sampling efficiency

•A malleable, semi-rigid wire is encased in the body of the Oral-Trac®TRUNK

•The TRUNK can be easily hand contoured in front of the oral cavity to provide accurate readings

•Malleable, semi-rigid wire is non-ferrous •Permits use in MRI suite•Dual port Salter Eyes® in nasal prongs •Safety apertures help to reduce possible

occlusions

•Facepiece anatomically curved to fit upper lip •Comfortable, secure fit. No irritating flaps or ridges

ARRHYTMIA DETECTION

Accessories

• For the comfort of patients:

• Mattresses for the operating table• Leg rest…• Head rest..• Warming blankets• Forced air warming blankets..

Positioning mattresses

SURGI-PRESSTM INFUSER

Warmer

Warming mattress

DISCHARGE

Evaluation of recovery after sedation(+/-analgesia):1

• “Street fitness”=home discharge• Blood pressure stable :± 20% basal• Oxygen saturation:± 20% basal• Pulse:± 20% basal• Mental state; ±20% (attention,concentration test,etc..)• Equilibrium;walking unassisted• Ability to dress• Ability to tolerate oral fluids • Absence of bleeding ,nausea(significant)• Voiding?(mannitol…..)• Scores:Aldrete…..

Evaluation of recovery after sedation(+/-analgesia):2

• Easy arousability, full orientation ,• Ability to maintain and protect the• airway,• Stable vital signs for at least one hour,• The ability to call for help if necessary,• Ability to unassisted ambulation,• Ability to tolerate oral fluids,• Ability to void, • Absence of significant pain or bleeding• Adult companion

DOCTOR’S CASEBOOK ...

SOME PARADIGMATIC CASES ….IMPORTANCE OF A LITTLE EXTRA TIME…………

5 15 25 350

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PASPADFcSaO2

Clonid 150 microgr+Diaz 5 mg p.os

RB,72,kg 75,cm 176,ASA 3(hypert,reumat,light diab)

Desat!!!vasoconstriction.

MLR,87a,85kg,170 cm,Asa 3(IPERTENS,PROT.AORT,bav1)

bas 20 40 60 70 80 90100

110120

130140

0

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PasPadFCetCO2

DIAZ 5+2CLONID 150

MIDAZ 2 FENT25 MIDAZ 0,5FENT 25

SEDUTA

ATTESA

Csi Danmeter

M.S,53 y,85 kg,180 cm,ASA 1(24/3/11)

bas 5 10 15 20 25 300

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PASPADFC

Clonidine 150 mcg+diaz 5 mg

C.O.,60 yr,66 kg,163 cm,ASA 3(Rh arthrt,ipertens,ipoacus)

bas 5 10 15 200

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PASPADFC

Clonidine 150 mcg+diaz 5 mg

DeG. L.,71,77,160,Asa 2(ipertens)

bas 5 10 15 20 25 30 35 400

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PASPADFC

Clonidine 150 mcg+diaz 5 mg

Sergio A.l 62 a,107 kg,199 cm,muratore!,ASA 1.

bas 5 10 15 20 25 300

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PASPADFC

Diaz 8 mg

bas 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 105 110 115 120 125 130 135 140 145 150 155 160 1650

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PAS

PAD

FC

clonid 150 microgdiaz 5 mg

Mannitol 18% 250

clonid 150 microgrMIDAZ 2 mg

Urapidil 100

NTG 5/ mg250 ml

sittin

g

supine

saline 250 ml

sitting,ok

V. M.80 yr,70 kg,164 cm ,ASA1(13/4/11)

Sedation too deep??

PP,F,56 a,kg50,cm 160,ASA 1

bas 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 1001051101151201251301351401451501551601651700

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PASPadFCSaO2etCO2

15.55

15.55 ini op.

Midaz 0,5

Fent 25 +fent 25

Atropa 0,5

Midaz 0,5 +fent 25 +fent 25 Midaz 0,5+midaz 0,5

Dorme:Ramsey 4 Sveglia!

14.50;clonid 150+diaz 5:si addomenta sulla popltrona della presala!

Midaz 0,5+fent 12,5

Perfalgan 1000

ZC,87a,kg80,cm 160,ASA3(BPCO asmatif,ipert)

0 5 0 15 20 25 300

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PASPADFcSaO2

diaz 5 mg 30 min before.

Clonid 90 microgr

Atropa o,5 mg

Lidocaine slow infus *cough control

PL,83a,44 kg,150 cm,ASA 1,diaz 4 mg premed 20 min before

0 5 10 15 20 25 30 350

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PASPADFcSaO2

Midaz 1 mgClonidine 90 mg

PREVENTION OF OTHER COMPLICATIONS

Ko:personal statistics• Excimer laser:

• 3 vasovagal reactions,1 severe and long lasting:incidence 8-10%

• FAG;– 1 vasovagal reaction,severe:;phedrine,atropine,fluids,supine 30’,Oxygen:incidence 10%– 1 allergic reaction;hypotension ,erythema;incidence 5% .

• Avastin;– Severe hypertension common ;generally no treatment or raraely anxiolysis

– Other• 1 haemorhage during cheek pithelioma dissection:fluids++

Cataract;– Arrival hypertension common ----clonidine 150 microgr in premed ,for all(sometime)s 75 – 1 severe pre/ and intraop hypertension:NTG;incidence 0.3%– 4 arrythmias atropine,lidocaine;sotalol incidence;1%,– Intraop bardycardia:6 cases :atropine;incidence 2% – 1 PONV – 2 postop syncopal reaction:,1 during discharge:fluids,ephedrine;incidence 0.5%– Need for deep sedation:2 cases 1 during IFIS.

Conclusions:which are the benefits having an anesthesiologist during the case?

• Benefits of an expert;– sedation,analgesia,general anesthesia just in case,– perioperative medicine(“the internist of the O:R”

• However ... sedation/anakgesia mya increase complications(nausea,PONV;discharge delay...)

• Treating patient discomfort• Preventing ortreating complications;pain,arrhytmias,blood

pressure elevations,anxiety....• Liability of MD vs CRNA,reason to prefer an anesthesiologist• Weeding out risky patients • Surgeon only focus is surgery?

conclusion

• Anesthesiologst useful,probably necessary.........

Key Components of Risk Associated with OphthalmicAnesthesia

Anesthesiology 2006; 105:859

Sedation risk

• Disorientation—head movement• Restlessness• If a patient is unable to tolerate a

block…..would he feel better with sedation?

Risk of eye injury during anesthesia for eye surgery

• Regional anesthesia technique(US??,blunt cannulas??)

• Education,experience• Movements,coughing during surgery

Ngozi Imasogie FRCA, David T. Wong MD, Ken Luk BSc, Frances Chung FRCPC.Elimination of routine testing in patients undergoing

cataract surgery allows substantial savings in laboratory costs. A brief report. CAN J ANESTH 2003 / 50: 3 / pp 246–248

• Editor:—I read with interest the closed claims analysis “Injury and• Liability Associated with Monitored Anesthesia Care” by Bhananker et al.1• and the accompanying editorial opinion by Hug.2 The study indicated that• more than one in five monitored anesthesia care claims in the database• occurred with patients undergoing elective eye surgery. It also reiterated• that the most common causes of patient eye injury and anesthesiologist• liability linked to ophthalmic anesthesia consisted of complications related• to the eye block and perioperative patient movement. More than four• fifths (83%) of ophthalmic anesthesia monitored anesthesia care cases• associated with inadequate anesthesia and/or patient movement, either• during the block or intraoperatively, resulted in ocular injury and, presumably,• poor visual outcome. A previous American Society of Anesthesiologists• Closed Claims Project, “Eye Injuries Associated with Anesthesia”• by Gild et al.3 published in the Journal identified 21 cases of blindness• allegedly the result of intraoperative movement during ophthalmic surgery.• Movement was the foremost mechanism of injury cited. Five of• those claims occurred during regional anesthesia and were attributed to• “restlessness” or coughing during the procedure.• Regional anesthesia is a vital part of the scope of anesthesia practice.• Because of its safety and efficacy, it is a preferred option for many• ophthalmic surgical procedures.4 Aside from intraoperative analgesia and• akinesia, advantages of conduction anesthesia for ophthalmic surgery• patients include suppression of the oculocardiac reflex and provision of• postoperative pain relief. In those eye cases where general anesthesia has• been the traditional modality of choice, such as open-globe injuries,• regional anesthesia may be a fitting alternative when general anesthesia• confers an unacceptable level of systemic or ophthalmic risk.5,6• Globe puncture is a dreaded complication of needle-based ophthalmic• regional anesthesia. Its incidence varies inversely with education• and experience. This is confirmed by a number of previous reports of• adverse sequelae by inadequately trained/educated anesthesia personnel.• 7–9 As noted in a previous letter to the Journal, no formal training• or education in ophthalmic regional anesthesia is provided to anesthesia• residents in the majority of programs.10,11 Anesthesiologists can• acquire these skills via university programs, Refresher Courses, and• workshops at the annual American Society of Anesthesiologists meeting• or though an organization such as the Ophthalmic Anesthesia• Society. In addition, newer ophthalmic anesthesia techniques may• minimize the risk of iatrogenic globe puncture. Ultrasound guidance• allows for direct visualization of the needle, whereas sub-Tenon regional• anesthesia replaces needles altogether with blunt cannulas.12,13• Topical anesthesia has gained acceptance for surgical procedures of the• anterior segment of the eye. Its use, particularly for cataract operations,• has surged in recent years.14 Topical anesthesia does not render the eye• akinetic, and requires the patient to focus on the microscope light.• Because oversedation may precipitate patient movement and depth of• analgesia may be less than with traditional regional anesthesia techniques,• the term “vocal local” has been used to describe the occasional reality of• ophthalmic anesthesia via topical anesthesia and minimal sedation.15• Regional and topical anesthesia for ophthalmic surgery are certainly not• without inherent risks. Unlike general anesthesia, these techniques mandate• patient cooperation. Because the majority of ophthalmic surgical cases are• elective, the article by Bhananker et al., as well as others, attests to the• wisdom of postponing surgery until such time that the patient is in optimal• condition to remain still if an increased risk of perioperative movement is• noted during the anesthesiologist’s preoperative assessment.1,3,16• Patient movement during block or intraoperatively due to cough,• fluctuating levels of consciousness, rebreathing of carbon dioxide• under occluded drapes, or restlessness with prolonged duration of• surgery can induce dire visual consequences. Deliberate patient selection• and judicious choice of suitable anesthesia technique is requisite• to determine the optimal anesthesia care prescription.• Steven Gayer, M.D., M.B.A., Bascom Palmer Eye Institute and• University of Miami Miller School of Medicine, Miami, Florida.• sgayer@med.miami.edu

• References• 1. Bhananker SM, Posner KL, Cheney FW, Caplan RA, Lee LA, Domino KB:• Injury and liability associated with monitored anesthesia care: A closed claims• analysis. ANESTHESIOLOGY 2006; 104:228–34• 2. Hug CC: MAC should stand for maximum anesthesia caution, not minimal• anesthesiology care. ANESTHESIOLOGY 2006; 104:221–3• 3. Gild WM, Posner KL, Caplan RA, Cheney FW: Eye injuries associated with• anaesthesia: A closed claims analysis. ANESTHESIOLOGY 1992; 76:204–8• 4. Eke T, Thompson JR: The National Survey of Local Anaesthesia for Ocular• Surgery: II. Safety profiles of local anaesthesia techniques. Eye 1999; 13:196–204• 5. Scott IU, McCabe CM, Flynn HW Jr, Lemus DR, Schiffman MS, Gayer S: Local• anaesthesia with intravenous sedation for surgical repair of selected open globe• injuries. Am J Ophthalmol 2002; 134:707–11• 6. Scott IU, Gayer S, Voo I, Flynn HW Jr, Diniz JR, Venkatraman A: Regional• anaesthesia with monitored anaesthesia care for surgical repair of selected open• globe injuries. Ophthalmic Surg Lasers Imaging 2005; 36:122–8• 7. Grizzard WS, Kirk NM, Pavan PR, Antworth MV, Hammer ME, Roseman RL:• Perforating ocular injuries caused by anesthesia personnel. Ophthalmology 1991;• 98:1011–6• 8. Hay A, Flynn HW Jr, Hoffman JI, Rivera AH: Needle penetration of the globe• during retrobulbar and peribulbar injections. Ophthalmology 1991; 98:1017–24• 9. Duker JS, Belmont JB, Benson WE, Brooks HLJr, Brown GC, Federman JL,• Fisher DH, Tasman WS: Inadvertent globe perforation during retrobulbar and• peribulbar anesthesia: Patient characteristics, surgical management, and visual• outcome. Ophthalmology 1991; 98:519–26• 10. Gayer S, Cass G: Sub-Tenon techniques should be one option among many• (letter). ANESTHESIOLOGY 2004; 100:196• 11. Miller-Meeks MJ, Bergstrom T, Karp KO: Prevalent attitudes regarding• residency training in ocular anesthesia. Ophthalmology 1994; 101:1353–6• 12. Birch AA, Evans M, Redembo E: The ultrasonic localization of retrobulbar• needles during retrobulbar block. Ophthalmology 1995; 102:824–6• 13. Guise PA: Sub-Tenon anesthesia: A prospective study of 6,000 blocks.• ANESTHESIOLOGY 2003; 98:964–8• 14. Leaming DV: Practice styles and preferences of ASCRS members: 2003• survey. J Cataract Refract Surg 2004; 30:892–900• 15. Claoue´ C: Simplicity and complexity in topical anaesthesia for cataract• surgery. J Cataract Refract Surg 1998; 24:1546–7• 16. Lee LA, Posner KL, Domino KB, Caplan RA, Cheney FW: Injuries associated• with regional anesthesia in the 1980s and 1990s: A closed claims analysis.• ANESTHESIOLOGY 2004; 101:143–52

Cataract Patient Whose Eyeball "Exploded" Wins $925K SettlementBotched anesthesia injection left man with right-eye blindness and pain.

Published:June 30, 2011.Outpatient surgery dec 2012.

• AnesthesiaOphthalmologySafetyNews

• A cataract surgery patient's eyeball exploded when a resident physician mistakenly injected local anesthetic directly into the man's right eye rather than behind it, according to the patient's lawyer.

• • The alleged incident, which left the man with permanent damage to his right eye, happened at a West Haven, Conn., Veterans Affairs

hospital in 2007. Earlier this week, the U.S. Department of Veterans Affairs agreed to pay nearly $1 million to settle a malpractice lawsuit brought by the patient, 60-year-old Army veteran Jose Goncalves.

• • According to Mr. Goncalves' lawsuit, the injury occurred when a third-year resident at the hospital incorrectly administered local

anesthesia directly into the patient's eye. She first placed the needle in the wrong spot and then, failing to realize her mistake, "proceeded to inject so much anesthetic, so quickly, that Jose's eye literally exploded," Christopher Bernard, attorney for Mr. Goncalves, tells the Connecticut Post. The lawsuit blames the incident on poor training of the resident.

• • In addition to losing sight out of his right eye, Mr. Goncalves also suffered "excrutiating pain" after the botched procedure and

"continued to have severe pain for months afterward," says Mr. Bernard. Because of his loss of vision and depth perception, he is no longer able to continue his previous career as a roofer; he now works in the maintenance department at a state university.

• • The VA settled the case just as it was being prepared for trial, agreeing to pay Mr. Goncalves $925,000. The U.S. attorney's office has

declined to comment.• • Irene Tsikitas

Risk of eye injury during anesthesia for eye

surgery ;data:• ASA Closed claim .Cheney FW. High-severity injuries associated with regional

anesthesia in the 1990s. American Society of Anesthesiologists Newsletter 2001;65:6– 8.– 71 permanent disabling injuries among the 308 claims. – The most common of these (23%) was associated with

nerve blocks of the eye (13 retrobulbar, 3 peribulbar),and typically the injury entailed loss of vision.

– Second in frequency (21%) were pain-management related claims involving, for example, neuraxial opiates or neurolytic blocks.

– Third in frequency (20%) were nerve injuries ssociated with neuraxial and peripheral blocks followed by epidural hematomas (13%).

• In 3 claims, patients were left unmonitored after retrobulbar blocks with sedation and developed respiratory and/or cardiovascular collapse.

Fatal Cataract Sedation Results in $2.1M SettlementPatient "inexplicably left alone" and unmonitored before surgery.

• Published: January 24, 2014

• The estate of a cataract patient whose routine sedation was fatally complicated by negligent monitoring has agreed to a $2.1 million settlement, according to court records.

• Marie Golubski, then 68, was scheduled to undergo cataract surgery on her right eye at the Pittsburgh-area Associates Surgery Center in June 2010. She was prepped and intravenously sedated before being "inexplicably left alone."

• During this time her breathing slowed significantly and the medical staff, having neglected to monitor her vital signs, failed to notice that she had fallen into respiratory and cardiac arrest. Twenty-three minutes after the IV sedation had been administered, she was discovered unresponsive and suffering anoxic brain injury, according to court records. She was transferred to a nearby hospital for resuscitative efforts, but died 6 days later.

• Ms. Golubski's husband filed suit, citing negligence in failing to monitor her, failing to provide continuous care and leaving her unattended after sedation. The defendants denied negligence. According to a case summary, ophthalmic surgeon Daniel Zimmer, MD, and anesthesia provider Brian Cross, CRNA, each argued that monitoring was the other's responsibility.

• In the August 2013 settlement, however, Dr. Zimmer, Mr. Cross, the surgery center and Dr. Zimmer's practice settled the case for a total of $2,125,000 in damages.

• Attorneys for Ms. Golubski's estate and the defendants did not immediately return calls seeking comment.

Anesthesiology 2004; 101:143–52.Injuries Associated with Regional Anesthesia in the 1980s and 1990s.A Closed Claims Analysis.Lorri A. Lee, Karen L. Posner, Karen B.

Domino, M.P.H.,Robert A. Caplan,Frederick W. Cheney.

Contraindications of local/regional anesthesia

• Pts unable to cooperate(mental impairment,dementia,Alzheimer’s)

• Difficult communication(inability to speak the language,deafness)• Involuntary movements:Parkinson’s disease..• Unable to lie flat or still:(CHF,COPD chest up,pillows….)• Uncontrolled coughing or sneezing:chronic bronchitis…

• Fentanyl • Severely anxious or claustrophobic: diazepam,midazolam…• Bilateral surgery• Prolonged or difficult surgery anticipated• Preference for GA,wether by the patient or surgeon or the

anesthetist…

PHENYLEPHRINE

Intraocular use of large doses of phenylephrine

• has been reported to cause severe cardiovascular compromise and possibly death. – [2. Van der Spek AF: Cyanosis and cardiovascular depression in a neonate:

Complications of halothane anesthesia or phenylephrine eyedrops? Can J Ophthalmol 1987; 22: 37-9 Abstract

3. Greher M, Harmann T, Winkler M, Zimpfer M, Crabnor CM: Hypertension and pulmonary edema associated with subconjunctival phenylephrine in a 2-month-old child during cataract extraction. ANESTHESIOLOGY 1998; 88: 1394-6 Full Text

4. Fraunfelder FT, Scafidi AF: Possible adverse effects from topical ocular 10% phenylephrine. Am J Ophthalmol 1978; 85: 447-53 Citation 2] [3] [4]

• New York State Guidelines on the Topical Use of Phenylephrine in the Operating Room

• Anesthesiology - Volume 92, Issue 3 (March 2000) -

• Scott B. Groudine M.D.*, Ingrid Hollinger M.D. , Jacqueline Jones M.D. , Barbara A. DeBouno M.D., M.P.H.§

The following is a summary of the guidelines circulated to NYS hospitals:1)

• 1. The initial dose of phenylephrine for adults should not exceed 0.5 mg (four drops of a 0.25% solution). This dosage is based on the product insert (Neo-Synephrine Sanofi, New York, NY) for the intravenous administration of phenylephrine for the treatment of mild/moderate hypotension. This dosage assumes 100% absorption of the administered phenylephrine. In children (up to 25 kg), the initial dose should not exceed 20 mug/kg. [25]

2. The minimal amount of phenylephrine needed to achieve vasoconstriction should be administered. BP and pulse should be closely monitored after phenylephrine is given.

3. The dose of phenylephrine should be administered in a calibrated syringe and should be verified by a physician.

4. The anesthesiologist should be aware of all medications that are administered to the patient perioperatively.

5. Mild-to-moderate hypertension resulting from phenylephrine use, in a healthy individual, should be closely monitored for 10-15 min before antihypertensive medications are given. Severe hypertension, as well as its adverse effects such as electrocardiographic changes or pulmonary edema, must be treated immediately. Antihypertensive agents that are direct vasodilators or alpha-receptor antagonists are appropriate treatments.

Visumidriatic fenilefrina

• Flacone da 10 ml con 50 mg di tropicamide e 1 gr di fenilefrina:1000 mg di fenilefrina ,100 mg /ml se 1 gt è 1/10 di ml,1 gt contiene 10 mg!!!!

• Il prodotto contiene sodio metabisolfito; tale sostanza può provocare in soggetti sensibili e particolarmente negli asmatici reazioni di tipo allergico ed attacchi asmatici gravi.

• Questa specialità medicinale contiene sodio etilmercurio tiosalicilato ( un composto organomercuriale) come conservante e, quindi, possono verificarsi reazioni di sensibilizzazione (vedi paragrafo 4.8).

Fenilefrina cloridrato in commercio in Italia 22 results found for FENILEFRINA-CLORIDRATO (303001)

AIC/EMEA Name Brand

030969012 FENILEFRINA CLOR.*OFT 5ML0,25% ALFA INTES (IND.TER.SPLENDORE)

030969024 FENILEFRINA CLOR.*OFT 10ML0,25 ALFA INTES (IND.TER.SPLENDORE)

030969036 FENILEFRINA CLOR.*OFT 5ML 1% ALFA INTES (IND.TER.SPLENDORE)

030969048 FENILEFRINA CLOR.*OFT 10ML 1% ALFA INTES (IND.TER.SPLENDORE)

030969051 FENILEFRINA CLOR.*OFT 5ML0,25% ALFA INTES (IND.TER.SPLENDORE)

030969063 FENILEFRINA CLOR.*OFT 10ML0,25 ALFA INTES (IND.TER.SPLENDORE)

038070013 NASOMIXIN CM*GTT 15ML 2,5MG/ML TEOFARMA Srl

016308025 RIBEX NASALE*SPRAY 15ML JOHNSON & JOHNSON SpA

011621012 ISONEFRINE*COLL 5ML 10% TUBILUX PHARMA SpA

011621024 ISONEFRINE*POM OFT 5G 10% TUBILUX PHARMA SpA

021953017 OPTISTIN*COLL 10ML 0,12% TUBILUX PHARMA SpA

006911010 ADRIANOL*SPRAY NAS 10ML 0,25% BOEHRINGER INGELHEIM IT.SpA

029676018 FENILEFRINA CLORID.*0,25% 10ML DYNACREN Lab.Farmaceutico Srl

032694010 FENILEFRINA CLOR.*OFT 10ML0,25 C.O.C. FARMACEUTICI Srl

011621036 ISONEFRINE*COLL 1FL 5ML 36% BAUSCH & LOMB-IOM SpA

021579014 OPTISTIN*COLL 10ML 0,12% TUBILUX PHARMA SpA

029743010 FENILEFRINA CLORID.*0,25% 10ML OGNA GIOVANNI & FIGLI SpA

029743022 FENILEFRINA*0,25% 10ML C/NEBUL OGNA GIOVANNI & FIGLI SpA

029909013 FENILEFRINA CLORID.*0,25% 10ML A.F.O.M. MEDICAL SpA

006769018 NEOSYNEPHRINE*SOLUZ 10ML 0,25% TEOFARMA Srl

006769020 NEOSYNEPHRINE*GTT 15ML 2,5MG/M TEOFARMA Srl

026627012 MINIMS FENILEFRINA*GTT OFT 10% SMITH & NEPHEW Srl(DIV.SANIT.)

Fenilefrina bassa concentrazione 0.12% OPTISTIN*COLL 10ML 0,12% TUBILUX PHARMA SpA

=1,2 mg/mlVisadron 0,125% BOEHRINGER INGELHEIM IT.

0,25% FENILEFRINA CLOR.*OFT 5ML0,25% ALFA INTES (IND.TER.SPLENDORE)

=2,5 mg/ml FENILEFRINA CLOR.*OFT 10ML0,25 ALFA INTES (IND.TER.SPLENDORE)

FENILEFRINA CLORID.*0,25% 10ML DYNACREN Lab.Farmaceutico Srl

FENILEFRINA CLOR.*OFT 10ML0,25 C.O.C. FARMACEUTICI Srl

FENILEFRINA CLORID.*0,25% 10ML OGNA GIOVANNI & FIGLI SpA

FENILEFRINA*0,25% 10ML C/NEBUL OGNA GIOVANNI & FIGLI SpA

FENILEFRINA CLORID.*0,25% 10ML A.F.O.M. MEDICAL SpA

NEOSYNEPHRINE*SOLUZ 10ML 0,25% TEOFARMA Srl

NEOSYNEPHRINE*GTT 15ML 2,5MG/M TEOFARMA Srl

Fenilefrina ad alta concentrazione 1% FENILEFRINA CLOR.*OFT 5ML 1% ALFA INTES (IND.TER.SPLENDORE)

=10 mg/ml FENILEFRINA CLOR.*OFT 10ML 1% ALFA INTES (IND.TER.SPLENDORE)

10% ISONEFRINE*COLL 5ML 10% TUBILUX PHARMA SpA

=100 mg/ml ISONEFRINE*POM OFT 5G 10% TUBILUX PHARMA SpA

MINIMS FENILEFRINA*GTT OFT 10% SMITH & NEPHEW Srl(DIV.SANIT.)

FENILEFRINA:assumendo che 15 gtt = 1 ml,

Concentrazione % Mg/ml Mg/goccia Microgr/gtt

0.12 1.2 0.08 80

0.25 2,5 0,166 166,66

0.5 5 0,333 333

1 10 0,666 666

10 100 6,66 6660

       

Phenylephrine usage in hypotension following spinal anesthesia for C/S

• intermittent bolus (120 μg) or a fixed-rate infusion (120 μg/min) regimen of phenylephrine:total infusion group received .(1740 (613) versus 964 (454) μg):

– Anesth Analg. 2012 Dec;115(6):1343-50. Phenylephrine infusion versus bolus regimens during cesarean delivery under spinal anesthesia: a double-blind randomized clinical trial to assess hemodynamic changes.Doherty A, Ohashi Y, Downey K, Carvalho JC

• Boletti di 50 microgr alla volta per ipotensione durante C/s in spinale:

– Anaesthesia. 2012 Dec;67(12):1348-55. Closed-loop double-vasopressor automated system to treat hypotension during spinal anaesthesia for caesarean section: a preliminary study.Sia AT, Tan HS, Sng BL.

Dosaggi di fenilefrina (e.v.)somministrata per ipotensione:

• In un trial clinico recente in pazienti sottoposti a endoarterectomia carotidea il farmaco sarebbe stato impiegato in boletti da 50 o 100 microgrammi per ristorare la PA in caso di ipotensione – Trials. 2013 Feb 14;14:43. Phenylephrine versus ephedrine on cerebral perfusion during carotid

endarterectomy (PEPPER): study protocol for a randomized controlled trial.Pennekamp CW, Immink RV, Buhre WF, Moll FL, de Borst GJ. ;

dosaggio di 100 microgr è stato scelto per contrastare la sindrome di ipotensione postperfusione nei trapiantati di fegato (Liver Transpl. 2012 Dec;18(12):1430-9. Epinephrine and phenylephrine pretreatments for preventing postreperfusion syndrome during adult liver transplantationRyu HG, Jung CW, Lee HC, Cho YJ.)

• Una recentissima review della fenilefrina nel trattamento e prevenzione della ipotensione materna e benessere neonatale in ostetricia ha suggerito come ottimali infusioni tra 25 e 50 microgr/min – (Anesth Analg. 2012 Feb;114(2):377-90. A review of the impact of phenylephrine

administration on maternal hemodynamics and maternal and neonatal outcomes in women undergoing cesarean delivery under spinal anesthesia.Habib,AS.

summary of the guidelines circulated to NYS hospitals:2)

• 6. The use of beta blockers and calcium-channel blockers should be avoided when vasoconstrictive agents such as phenylephrine are used in the operating room. Case reviews, as well as a review of the medical literature, suggest that the use of beta blockers, and potentially calcium-channel blockers, as treatment of hypertension secondary to a vasoconstrictor may worsen cardiac output and result in pulmonary edema.

• Unfortunately the specific alpha blocking drug phentolamine is not readily available…………….

7. If a beta blocker is used for the treatment of resulting hypertension, glucagon may be considered to counteract the loss of cardiac contractility as well as other standard therapies.

• • In conclusion, it is hoped that these guidelines will result in more cautious use of

phenylephrine in ENT surgery and alert the anesthesia community to the potentially lethal dangers of treating alpha-agonist-induced hypertension with cardiac-depressant therapies.

PONV

Haloperidol+dexamethasone • Eur J Anaesthesiol. 2010 Feb;27(2):192-5.• Effectiveness of combined haloperidol and dexamethasone versus dexamethasone only for

postoperative nausea and vomiting in high-risk day surgery patients: a randomized blinded trial.

• Chaparro LE, Gallo T, Gonzalez NJ, Rivera MF, Peng PW.– 160 high-risk patients undergoing ambulatory

surgery.(nonsmoking,women ,18 -50 ), cosmetic or ENT surgery,

– 1.5 mg of haloperidol 30’ before end of surgery + 8 mg of dexamethasone preop reduces the cumulative incidence of postoperative vomiting at 6 and 24 h postoperatively

author Drugs(microgr/kg) POV incidence %

Splinter ,Anesthesiology 1998 Ondansetron 150 28

Ondansetron 50 +dexamethasone 150 9

Splinter ,Paediatr Anaesth.2001

Dexamethasone 150 23

Dexamethasone 150+ondansetron 50 5

Bhardway J.Pediatr Ophtalmol Strabismus 2004

Placebo 64,5

Ondansetron 150 33,3

Ondansetron 150+dexamethasone 200 10

Combination antiemetic therapy in paediatric strabismus surgery :ondansetron and dexamethasone

AnaesthesiaTo be read in conjunction with The Royal College of Ophthalmologists/Royal College of Anaesthetists guidelines

‘Local anaesthesia for intraocular surgery’6.1 Background

• There has been a dramatic change of anaesthetic practice for ophthalmic surgery over the past decade. The• use of local anaesthesia (LA) has ri sen from around 20% in 19911 to over 75% in 19962a and 86% in 19973• and the use of sedation with LA has fal len from 45% in 1991 to around 6% in 1996.2a• Successful day case cataract surgery has been reported using different GA techniques4 and LA techniques.5,6,7• Most patients presenting for cataract surgery are elder ly and have pre-existing medical problems. A local• anaesthetic i s preferable, particular ly for small incision surgery, as it wi ll usually be associated with lower• morbidi ty and i t causes least disruption to daily routine.• The 1996 National Survey of Local Anaesthesia for Ocular Surgery confirmed that ser ious systemic adverse• events may occur w ith all types of LA, but are rare (3.4 per 10,000), although a degree of under-reporting was• suspected.2b These events are not reduced by routine pre-operative investigations.8,9• No LA technique is totally free of the r isk of a serious systemic adverse event . This is not necessari ly a• consequence of a particular local anaesthetic technique. Other factors include pre-existing medical conditions,• anxiety, pain or stress reaction to the operation.• 6.2 Organisation of ophthalmic anaesthetic services• • Multi-professional teamwork is the key to day case cataract surgery and i s essential at every stage of the• process• • Every unit should identify an anaesthetist with overal l responsibili ty for ophthalmic serv ices• • Meticulous recording of important data is a necessary prerequisi te for good communication, safe practice,• cl inical governance and audit• 6.3 Recomm ending the type of anaesthesia• The surgical assessment should include recommendations on the type of anaesthetic indicated for the• indiv idual patient . This wil l depend on psychological aspects, the particular features of the globe and orbi t , and• the anticipated difficulty of the surgery.• 6.3.1 Pre-operative investigations• In a randomised survey of over 19,000 cataract operations, routine pre-operative medical• investigations did not reduce the incidence of peri -and post-operative morbidity.8• A prev ious study in a large teaching hospital show ed that even w hen routine investigations were performed,• the results were rarely taken into account.9• A• 19• To quote from the ‘Local Anaesthesia for Int raocular Surgery Guidelines’,• “Tests should only be considered w hen the history or a finding on physical examination would have indicated• the need for an investigation even i f surgery had not been planned…….Most abnormal ities that would be• detected on special testing (e.g. ECG, CXR, FBC, clotti ng studies, urea and electrolytes) can be predicted from• tak ing a careful history and performing a physical examination. Special tests do not reduce morbidity in this• context and are not required unless specifically indicated…For the patient with no history of significant systemic• disease and no abnormal findings on examination at the nurse-led assessment , no special investigations are• indicated. Any patient requiring special tests may need a medical opinion.”• • Hypertension should be controlled wel l before the patient is scheduled for surgery and not lowered• immediately pr ior to surgery.• • Angina should be control led by a patient ’s usual angina medication w hich should be avai lable in theatre.• Every effort should be made to make the experience as stress-free as possible. Generally patients should• not have surgery within three months of a myocardial infarct .• • Diabetic patients should have their blood sugar controlled. If surgery is planned under LA diabetic patients• should have their usual medication and oral intake.• • Patients with chronic obstructive pulmonary disease may benefit from an open draping system or a simple• venturi high flow oxygen enriched air system below the drapes.• • There is no need for antibiotic prophylaxis for int raocular surgery in patients w ith valvular heart disease.• • Those on Warfar in should have an INR (see below)• 6.3.2 Warfarin and cataract surgery• A recent rev iew of the available li terature10 reported RCTs which conclude that :• • Warfarin is effective at reducing heal th and l ife-threatening thrombotic events• • To stop Warfarin r isks stroke and death (events reported in questionnaires by those ophthalmologists who• stop Warfarin). The risk of stroke increases to 1:100• They suggested that for those on Warfar in:• • The INR should be checked to ensure that a patient is within their desired therapeutic range (set by the• treating physician)• • If needle local anaesthesia i s performed, the r isk of orbital haemorrhage i s increased by 0.2 – 1.0%• • Consideration should be given to using either sub-Tenon’s or topical anaesthesia.• 6.3.3 Aspirin and cataract surgery• The same rev iew of the l iterature suggested that aspir in was l ittle better than placebo in prevention of• thrombotic events in the two studies where these were compared with Warfarin.10 The inference, al though• this w as not stated in the paper, i s that aspir in could be discontinued without significant thrombotic ri sk .• 20• 6.4 General anaesthesia (GA)• A general anaesthetic i s not an exclusion to day case surgery4 and may be appropriate for patients w ho:• • decline to have local anaesthesia even after careful counsell ing and an explanation of the r isks involved• • are confused and unable to comply with inst ructions, or unable to communicate and w hose safety might be• compromised• • have a marked uncontrol led t remor• • have a medical condition severe enough to limit acceptable positioning• • are young - the age below which the clinician or patient prefers GA wil l be influenced by personal• preference and the culture of both parties• • have previously experienced a severe reaction, al lergy or other complication to local anaesthesia• Pre-operative fasting i s necessary for general anaesthesia only and should follow set protocols establi shed• local ly. Water can usually be taken until an hour before surgery. Patients should be inst ructed to take al l their• usual medication except for oral hypoglycaemic agents.• 6.5 Local anaesthesia (LA)• With the advent of small incision techniques using phacoemulsification there i s no longer a need for complete• akinesia, ocular hypotony or absence of lid movement and many would regard the only goal of local• anaesthesia to be pain-free surgery. This may be adequately achieved by most local anaesthetic techniques• including topical anaesthesia in many patients. The main disadvantage of topical anaesthesia i s the increased• surgical difficulty in the absence of ak inesia, and the possible need to augment the anaesthesia in the event of• intra-operative complications.• The goal of LA for intraocular surgery i s to:• • prov ide pain-free surgery• • minimise the r isk of systemic compl ications• • faci li tate the surgical procedure• • reduce the r isk of surgical compl ications• 6.5.1 Local anaesthetic techniques• Local anaesthesia for cataract surgery is administered either by injection or topical appl ication to the• conjunctiva. There are many techniques of local anaesthesia and practice var ies widely throughout the• world 9,11 and within the U.K. 2• The following techniques are used:• • Topical anaesthesia, alone, or in conjunction with preservative-free int racameral local anaesthetic• • Subconjunctival anaesthesia• • Sub-Tenon’s anaesthesia• 21• • Peribulbar (extracone) anaesthesia• • Retrobulbar (int racone) anaesthesia• All forms of cataract surgery with local anaesthesia demand significant patient co-operation throughout the• procedure. Co-operation is most important when procedures are performed with topical anaesthesia.• Patients being operated upon by this technique should be able to tolerate inst ruments approaching the eye• without anxiety or blepharospasm. This can be gauged pre-operatively. A separate VIIth nerve block i s not• general ly recommended.• Patients undergoing all forms of anaesthesia require adequate counsell ing and explanation of the• procedure. It i s unnecessary to fast patients for local anaesthetic cataract surgery.• 6.5.2 M inimising com plications• There are two cr itical issues in the debate about minimising compl ications associated with LA injection: needle• length and technique. Absolute distinction betw een peribulbar and retrobulbar injection cannot always be• made, but complications of both are reduced by using a short (25-31 mm) needle.12 It follows that longer• needles are associated with a higher r isk of complications.• Although ocular perforation has been reported with an intended sub-Tenon’s anaesthetic (STLA) (the• perforation occurred during the preparatory dissection in a patient with previous retinal detachment surgery13),• it is generally accepted that the r isk of t rue perforation is much lower in blunt-cannula STLA than in needle• local techniques. Needle anaesthesia should be avoided where possible in the high myopes.• Systemic adverse events have been reported in all forms of local anaesthesia including topical.2b• 6.5.3 Choice of local anaesthetic technique• In deciding which type of anaesthesia to use, the following factors should be considered.• PATIENT FACTORS• All forms of cataract surgery with local anaesthesia require significant patient co-operation throughout the• procedure. Thus, patient preference, anxiety and abi lity to co-operate should all be taken into account .• • LA is the procedure of choice for the majori ty of patients, prov ided co-operation can be assured.• • The patient ’s abi lity to tolerate manipulation around the eye without blepharospasm should have been• gauged at the pre-operative assessment• • The experience of the anaesthetist (an inexperienced practitioner is l ikely to do less damage with a blunt• cannula than w ith a sharp needle)• SURGICAL FACTORS• • The type and size of incision• • Axial length• • The r isk of compl ications• • B• 22• • Duration of the operation• • The experience of the surgeon• 6.5.4 Who Should Adm inister LA?• Local anaesthetic injections should only be performed by anaesthetists or ophthalmologists who have been• trained appropriately. Nurses, technicians and others may be trained to administer topical , or subconjunctival• or sub-Tenon’s anaesthesia. In some centres, nurses have been trained to administer sub-Tenon’s blocks, but• the administ ration by these professionals of per ibulbar or retrobulbar injections is not recommended.• 6.6 Sedation for ocular anaesthesia• Ideal ly, the patient undergoing cataract surgery under local anaesthesia should be fully conscious, responsive,• and free from anxiety, discomfort and pain. For most this can be achieved by sensitive and personalised• assessment and counselling, with support throughout the operation and verbal reassurance. This is great ly• faci li tated by continuity of staff care at al l pre-operative stages. How ever a few patients require sedation (6%• in 1996).2a• Intravenous sedation should only be administered under the supervision of an anaesthetist , w hose sole• responsibil ity is to that l ist• Good rapport, counsel ling, support and the use of relatively painless techniques all reduce the need for• sedation• Sedation should only be used to al lay anxiety and not to cover inadequate blocks, which must be• corrected by the administration of more local anaesthesia• 6.7 Monitoring• Severe systemic complications are a w el l known, albeit rare complication of cataract surgery and have been• associated with all LA techniques. The patient should be assured that they wi ll be careful ly monitored.• 6.7.1 M ethods of M onitoring• Continuous monitoring of ventilation and circulation is essential, both by clinical observations, and by pulse• oximetry. Monitoring should commence just pr ior to the administ ration of local anaesthesia and continue until• the surgical procedure is ended. The level of monitor ing required during local anaesthesia wil l depend upon the• anaesthetic technique and the medical condition of the patient .• Monitor ing should be the role of a member of the staff who remains with the patient throughout the• monitor ing period and whose sole responsibi li ty i s to the patient . This person i s trained to detect and act on• any adverse events, and may be an anaesthetist, nurse, operating Department Practitioner (ODP), Assistant• (ODA) or anaesthetic nurse as long as they are t rained in basic life support (BLS)• All theatre personnel should participate in regular Basic Life Support (BLS) t raining, and there should• always be at least one person present who has Intermediate (ILS) or Advanced Life Support (ALS)• Training or an equivalent qualification.• • • • 23• 6.7.2 Level of monitoring required during cataract surgery under LA• • Communication with attendant• Probably the single most important monitor - an indiv idual w hose sole responsibi lity is to remain in contact with• the patient and who is trained to detect and act (or alert someone more senior) on any adverse event• • Cl inical observations• Monitor the patient ’s colour, responses to surgical stimulus, ventilatory movements and palpation of the pulse• • Pulse oximetry• To detect cardiac and respiratory problems prompt ly• • IV access• Essential if per ibulbar or ret robulbar techniques are employed or int ravenous sedation is used• 6.7.3 Level of staffing required during cataract surgery under LA• • The method of anaesthesia and local staffing avai labil ity wil l dictate w hether an anaesthetist can be• provided for all ophthalmic lists. An anaesthetist i s not essential when topical , subconjunctival or bluntcannula• sub-Tenon’s techniques without sedation are used• • An anaesthetist should be present i f retrobulbar, per ibulbar and sharp-needle sub-Tenon’s techniques are• used• • In the absence of an anaesthetist , the hospital , t rust or treatment centre is responsible for ensuring that• someone in the operating theatre is t rained to perform cardiopulmonary resusci tation• • Intravenous sedation should only be administered under the superv ision of an anaesthetist , whose sole• responsibil ity is to that l ist• 6.8 Facil ities• All int raocular surgery performed under LA should be carried out in a facil ity which i s appropriately equipped• and staffed for resusci tation. Oxygen and suction must be available. Patients should be on a tipping trolley or• equivalent chair.• 24• 6.9 Anaesthesia references• 1 Hodgkins PR, Luff AJ, Morrell AJ, Teye Botchway L, Featherston TJ, F ielder AR. Current practice of• cataract extraction and anaesthesia, Br J Ophthalmol 1992; 76: 323-326• 2a Eke & Thompson T, Thompson J R. The National Survey of Local Anaesthesia for Ocular Surgery. I.• Survey methodology and current practice. Eye 1999a; 13:189-195• 2b Eke T, Thomson JR. The National Survey of local anaesthesia for ocular surgery. II . Safety profiles of• local anaesthesia techniques. Eye 1999b; 13: 196-204• 3 Desai P, Reidy A, Minassian DC. Profile of patients presenting for cataract surgery : National data• collection. Br J Ophthalmol 1999;83:893-896• 4 Moffat A, Cul len PM. Comparison of two standard techniques of general anaesthesia for day-case• cataract surgery. Br J Anaesth 1995;74(2):145-8.• 5 Percival SP, Setty SS. Prospective audit comparing ambulatory day surgery w ith inpatient surgery for• treating cataracts. Qual Health Care 1992;1(1):38-42.• 6 Jain S, Adhikar i HP. Day case cataract surgery without a dedicated unit. J R Coll Surg Edinb• 1996;41(5):336-8.• 7 Hamil ton RC, Gimbel HV, St runin L. Regional anaesthesia for 12,000 cataract ext raction and int raocular• lens implantation procedures. Can J Anaesth 1988;35(6):615-23.• 8 Schein OD, Katz J, Bass EB et al . The value of routine pre-operative medical testing before cataract• surgery. New England J M ed 2000; 342: 168-176• 9 Walters G, M cKibbin M. The value of pre-operative investigations in local anaesthetic ophthalmic• surgery. Eye 1997;11: 847-849• 810 Konstantos A. Anticoagulation and cataract surgery: a rev iew of the current l iterature. Anaesth• Intensive Care 2001; 29: 11-18• 11 N orregard JC, Schein OD, Bellan L, Black C, Alonso J, Bernth-Petersen P, Dunn E, Anderson TF,• Espellargues M , Anderson GF. International variation in anaesthesia care during cataract surgery: Resul ts form• the international cataract surgery outcomes study. Arch Ophthalmol 1997;115(10):1304-1308.• 12 D avis DB, M andel M R. Efficacy and complication rate of 16,224 consecutive peribulbar blocks. A• prospective multicenter study. J Cataract Refract Surg 1994;20(3):327-37.• 13 Fr ieman BJ, Fr iedberg M A. Globe perforation associated w ith subtenon’s anesthesia. Am J• Ophthalmol 2001; 131 (4): 520-521

SCREENING PREOP/PATIENT EVALUATION

ANTICOAGULATION

Anticoagulants and platelet inhibitors. • A a study of 19,283 cataract surgeries, 13.8% of the 4588 aspirin users and 10.5% of the

752 warfarin users were advised to stop their aspirin or warfarin before surgery. The authors concluded that “There was no evidence to suggest that patients who continued use were at increased risk of ocular hemorrhagic events,nor that those who discontinued use were at increased risk of medical events for which these medications were routinely prescribed.” – Katz J, Feldman MA, Bass EB, et al; for the Study of Medical Testing for Cataract Surgery Study Team. Risks and benefits of

anticoagulant and antiplatelet medication use before cataract surgery. Ophthalmology 2003;110:1784–8.

• A recent multicentre audit of 55,567 cataract operations on patients taking antiplatelet and anticoagulant medications concluded that “Clopidrogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and sub-Tenon’s cannula local anesthesia, but was not associated with a significant increase in potentially sight-threatening local anesthetic or operative hemorrhagic complications.”– Benzimra JD, Johnson RL, Jaycock P, et al. The Cataract National Dataset electronic multicentre audit of 55,567

operations:antiplatelet and anticoagulant medications. Eye 2008 Feb 8 (Epub ahead of print).

• It has been estimated that a randomized clinical trial would require 20,000 patients on anticoagulants to definitively determine if the medical risks of discontinuing therapy outweigh the surgical risks of continuing therapy. Often patients are concomitantly taking Chinese herbal medicine and other supplements that may have anticoagulant properties or alter blood levels of anticoagulant medications. An International Normalized Ratio (INR) done preoperatively should e in the therapeutic range if injection block anesthesia is contemplated or for a combined procedure (e.g., trabeculectomy)

Jamula E, Anderson J, Douketis JD.Safety of continuing warfarin therapy during cataract surgery: a

systematic review and meta-analysis. Thromb Res. 2009 Jul;124(3):292-9. Epub 2009 Feb 23.

• Department of Medicine, McMaster University and St Joseph's Healthcare, Hamilton, ON, Canada.• Abstract• BACKGROUND: In patients who are receiving warfarin therapy and require cataract surgery, it may be possible to

continue warfarin in the perioperative period but the safety of this management strategy has not been systematically evaluated.

• METHODS: We performed a systematic review of the literature to assess the safety (bleeding events) of continuing warfarin before and after cataract surgery. We included studies that enrolled patients undergoing cataract surgery who were anticoagulated with warfarin alone and that reported bleeding events as an outcome. Study quality was assessed using a validated form. Odds ratios and bleeding rates were pooled to give summary estimates of bleeding risk.

• RESULTS: We identified 11 studies (5 cohort and 6 case series) assessing bleeding risk associated with warfarin continuation during cataract surgery. Patients who continued warfarin had an increased risk for bleeding (odds ratio; 3.26; 95% confidence interval [CI]: 1.73-6.16). The overall incidence of bleeding (95% CI) was 10% (5-19). Almost all bleeding events were self-limiting and not significant, consisting of dot hyphemae or subconjunctival hemorrhages. No patient had compromised visual acuity related to a bleeding event.

• CONCLUSION: Patients who are receiving warfarin therapy and undergo cataract surgery without warfarin interruption have an increased risk for bleeding but such bleeds are not clinically significant. The low quality of studies assessed, however, precludes definitive conclusions as to the risk for bleeding in patients who continue warfarin around the time of cataract surgery

Katz J, Feldman MA, Bass EB, Lubomski LH, Tielsch JM, Petty BG, Fleisher LA, Schein OD; Study of Medical Testing for Cataract SurgeryTeam.

Risks and benefits of anticoagulant and antiplatelet medication use before cataract surgery.Ophthalmology. 2003 Dec;110(12):2309. Sep;110(9):1784-8• Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland

21205-2103, USA. jkatz@jhsph.edu• OBJECTIVE: To estimate the risks and benefits associated with continuation of anticoagulants or antiplatelet

medication use before cataract surgery.• DESIGN: Prospective cohort study.

• PARTICIPANTS: Patients 50 and older scheduled for 19,283 cataract surgeries at nine centers in the United States and Canada between June 1995 and June 1997.

• MAIN OUTCOME MEASURES: Intraoperative and postoperative (within 7 days) retrobulbar hemorrhage, vitreous or choroidal hemorrhage, hyphema, transient ischemic attack (TIA), stroke, deep vein thrombosis, myocardial ischemia, and myocardial infarction.

• RESULTS: Before cataract surgery 24.2% and 4.0% of patients routinely used aspirin and warfarin, respectively. Among routine users, 22.5% of aspirin users and 28.3% of warfarin users discontinued these medications before surgery. The rates of stroke, TIA, or deep vein thrombosis were 1.5/1000 among those who did not use aspirin or warfarin and 3.8/1000 surgeries among routine users of aspirin and warfarin who continued their medication before surgery. The rate was 1 event per 1000 surgeries among those who discontinued aspirin use (relative risk = 0.7, 95% confidence interval = 0.1-5.9). There were no events among warfarin users who discontinued use. The rates of myocardial infarction or ischemia were 5.1/1000 surgeries (aspirin) and 7.6/1000 surgeries (warfarin) among routine continuous users and no different from those of routine users who discontinued use.

• CONCLUSIONS: The risks of medical and ophthalmic events surrounding cataract surgery were so low that absolute differences in risk associated with changes in routine anticoagulant or antiplatelet use were minimal

J Cataract Refract Surg. 2009 Oct;35(10):1815-20.Perioperative management of anticoagulated patients having cataract surgery:

National audit of current practice of members of the Royal College of Ophthalmologists. Batra R, Maino A, Ch'ng SW, Marsh IB.

• Department of Ophthalmology, University Hospital Aintree, Liverpool, United Kingdom. RuchikaBatra@aol.com

• Comment in: • J Cataract Refract Surg. 2010 Apr;36(4):701; author reply 701-2. • Abstract• An 11-item questionnaire was mailed to 891 consultant members of the Royal College of

Ophthalmologists (RCOphth) to audit compliance with RCOphth guidelines for perioperative management of anticoagulated patients having cataract surgery. Four hundred ninety-nine questionnaires were analyzed.(56%) The results showed that 29.5% of respondents adhered to all aspects of RCOphth guidelines; that is, they checked the international normalized ratio (INR) preoperatively, continued warfarin, operated within the desired therapeutic INR range for the condition that warfarin was being used to treat (as set by the treating physician), and considered sub-Tenon or topical anesthesia in anticoagulated patients.

Thromboembolic events according to management strategy Arch. Intern.Med.2003

Continuation of OAC

Discontinuation of AOC

Discontinuation of therapy with administration of i.v.heparin

Discontinuation of therapy with administrationOf LMWH

Discontinuation of therapy with administration of unclear therapy

1/237(0,4%)

6/996(0,6%)

0/166(0%)

1/180(0,6%)

21/263(8%)

Overall 29 thromboembolic events /1868 patients:7 strokes

Major bleeding events while receiving therapeutic OAC.(Arch Intern.Med 2003)

dental arthrocentesis Cataract surgery

upper endoscopy or colonoscopy with or without biopsy

4/2014(0.2%)

0/32(0%)

0/203(0%)

0/111(0%)

Arch Intern Med. 2003 Apr 28;163(8):901-8.Perioperative management of patients receiving oral anticoagulants: a systematic review.

Dunn AS, Turpie AG.

Department of Medicine, Mount Sinai School of Medicine, New York, NY 10029, USA. andrew.dunn@mountsinai.org

.safety and efficacy of various management strategies for patients receiving oral anticoagulants (OACs) who need to undergo surgery or invasive procedures .. systematic review and synthesis of the English-language literature examining the perioperative management and outcomes of patients receiving long-term OAC therapy.. 31 reports identified. . quality of the identified reports was generally poor; . no randomized controlled trials have been performed and duration of follow-up was typically not stated.

Arch Intern Med. 2003 Apr 28;163(8):901-8.Perioperative management of patients receiving oral

anticoagulants: a systematic review.Dunn AS, Turpie AG.• CONCLUSIONS:

• Most patients can undergo dental procedures, arthrocentesis, cataract surgery, and diagnostic endoscopy without alteration of their regimen.

• For other invasive and surgical procedures, oral anticoagulation needs to be withheld, and the decision whether to pursue an aggressive strategy of perioperative administration of intravenous heparin or subcutaneous low-molecular-weight heparin should be individualized.

• The current literature is substantially limited in its ability to help choose an optimal strategy. Further and more rigorous studies are needed to better inform this decision.

• Comment in• Dental procedures can be undertaken without alteration of oral anticoagulant regimen. [Evid Based Dent. 2005]• Oral anticoagulant and dental procedures. [Arch Intern Med. 2003]• Perioperative management of patients receiving oral anticoagulants. [Arch Intern Med. 2003]• The perioperative management of warfarin therapy. [Arch Intern Med. 2003]

The Cataract National Dataset electronic multicentre audit of 55,567 operations: antiplatelet and anticoagulant

medications:% complications

clopidogrel warfarin control

needle haematoma 8 6,2 4,3

subjunctival haemorrhage 4,4 3,2 1,7

any op.complication 7,3 ?? 4,4

post.capsular rupture 3,2 ?? 1,7

The Cataract National Dataset electronic multicentre audit of 55,567 operations: antiplatelet and anticoagulant medications:

% complications

needle h

aematoma

subjunctival

haemorrh

age

any op.co

mplication

post.cap

sular r

upture 0

1

2

3

4

5

6

7

8

clopidogrelwarfarincontrol aspirin only

The Royal College of Ophthalmologists of the UnitedKingdom (RCOphth) guidelines on the

perioperative management of the anticoagulated patient.2007

• (1) Warfarin is effective at reducing health and life-threatening thrombotic events.

• (2) To stop warfarin risks stroke and death. The risk for stroke increases to 1:100.

• (3)The INR should be checked to ensure that a patient is within the desired therapeutic range (set by the treating physician)

• (4) If needle local anesthesia is performed,the risk for orbital hemorrhage is increased by 0.2% to 1.0%.

• (5) Consideration should be given to using sub-Tenon or topical anesthesia.

Chest. 2008 Jun;133(6 Suppl):299S-339S.The perioperative management of antithrombotic therapy: American College of Chest

Physicians Evidence-Based Clinical Practice Guidelines (8th Edition).Douketis JD, Berger PB, Dunn AS, Jaffer AK, Spyropoulos AC, Becker RC, Ansell J;

American College of Chest Physicians.• McMaster University, Hamilton, Ontario, Canada.• Abstract• This article discusses the perioperative management of antithrombotic therapy and is part of the American College of Chest Physicians Evidence-Based Clinical

Practice Guidelines (8th Edition). The primary objectives of this article are the following: (1) to address the perioperative management of patients who are receiving vitamin K antagonists (VKAs) or antiplatelet drugs, such as aspirin and clopidogrel, and require an elective surgical or other invasive procedures; and (2) to address the perioperative use of bridging anticoagulation, typically with low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH). A secondary objective is to address the perioperative management of such patients who require urgent surgery. The recommendations in this article incorporate the grading system that is discussed in this supplement (Guyatt G et al, CHEST 2008; 133:123S-131S). Briefly, Grade 1 recommendations are considered strong and indicate that the benefits do (or do not) outweigh risks, burden, and costs, whereas Grade 2 recommendations are referred to as suggestions and imply that individual patient values may lead to different management choices. The key recommendations in this article include the following: in patients with a mechanical heart valve or atrial fibrillation or venous thromboembolism (VTE) at high risk for thromboembolism, we recommend bridging anticoagulation with therapeutic-dose subcutaneous (SC) LMWH or IV UFH over no bridging during temporary interruption of VKA therapy (Grade 1C); in patients with a mechanical heart valve or atrial fibrillation or VTE at moderate risk for thromboembolism, we suggest bridging anticoagulation with therapeutic-dose SC LMWH, therapeutic-dose IV UFH, or low-dose SC LMWH over no bridging during temporary interruption of VKA therapy (Grade 2C); in patients with a mechanical heart valve or atrial fibrillation or VTE at low risk for thromboembolism, we suggest low-dose SC LMWH or no bridging over bridging with therapeutic-dose SC LMWH or IV UFH (Grade 2C). In patients with a bare metal coronary stent who require surgery within 6 weeks of stent placement, we recommend continuing aspirin and clopidogrel in the perioperative period (Grade 1C); in patients with a drug-eluting coronary stent who require surgery within 12 months of stent

placement, we recommend continuing aspirin and clopidogrel in the perioperative period (Grade 1C). In patients who are undergoing minor dental procedures and are receiving VKAs, we recommend continuing VKAs around the time of the procedure and co-administering an oral prohemostatic agent (Grade 1B); in patients who are undergoing minor dermatologic procedures and are receiving VKAs, we recommend continuing VKAs around the time of the procedure (Grade 1C); in patients who are undergoing cataract removal and are receiving VKAs, we recommend continuing VKAs around the time of the procedure (Grade 1C).

Chest. 2008 Jun;133(6 Suppl):299S-339S.The perioperative management of antithrombotic therapy: American College of

Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition).Douketis JD, Berger PB, Dunn AS, Jaffer AK, Spyropoulos AC, Becker RC, Ansell J;

American College of Chest Physicians. 5.3.1 Patients Who Are Receiving VKAs

• 5.3.1 Patients Who Are Receiving VKAs • Six prospective cohort studies assessed bleeding in patients who continued VKA therapy during

ophthalmologic surgery and in a control group of patients who were either not receiving VKA therapy or who interrupted VKA therapy before surgery. [219] , [220] , [221] , [222] , [223] , [224] Two other prospective cohort studies assessed bleeding in patients who continued VKA therapy during ophthalmologic surgery but did not have a control group. [225] , [226] In one prospective cohort study assessing patients who had cataract surgery, there was no apparent increase in arterial thromboembolic events in 208 patients who discontinued VKAs compared to 526 patients who continued VKAs and the incidence of such events appeared higher in patients who continued VKAs (1.14% vs 0.48%).[221] In these patients, there were no major or clinically relevant nonmajor bleeds. In another cohort study involving 639 patients who continued VKAs and 1,203 controls who were not taking VKAs around the time of cataract surgery, there were no arterial thromboembolic events.[219] There appeared to be a higher incidence of clinically relevant nonmajor bleeding (0.16% vs 0.08%) and minor bleeding (1.41% vs 0.67%) in patients who continued VKAs although there were no major bleeds reported. While other smaller cohort studies demonstrated similar results, [225] , [226] one cohort study involving 125 patients who had cataract surgery reported a high rate of major bleeding (8.7%).[224]

Perioperative Management of Antithrombotic Therapy Patients Who Require Urgent Surgical or Other Invasive Procedures (American College of Chest Physicians Evidence-Based Clinical

Practice Guidelines (8th Edition). 2008 )

• 6.1 Patients Who Are Receiving VKAs • In the nonbleeding patient who requires rapid (within 12 h) reversal of the anticoagulant effect of VKAs because of an urgent surgical or other invasive procedure, treatment

options that have been assessed in observational studies include fresh-frozen plasma, prothrombin concentrates, and recombinant factor VIIa. [229] No randomized trials, to date and to our knowledge, have compared these treatments in patients who require urgent reversal of anticoagulation. [230] In addition to these treatment options, all patients should receive vitamin K, at a dose of 2.5 to 5.0 mg po or by slow IV infusion. [231] Administering fresh-frozen plasma, prothrombin concentrates, or recombinant factor VIIa alone will temporarily override but will not eliminate the anticoagulant effect of VKAs, which persist until VKAs are endogenously metabolized or neutralized by vitamin K. For example, as fresh-frozen plasma has an elimination half-life of 4 to 6 h, not administering vitamin K will lead to reemergence of a VKA-associated anticoagulant effect within 12 to 24 h. If surgery is urgent but can be delayed for 18 to 24 h, the anticoagulant effect of VKAs is likely to be neutralized by IV vitamin K, at a dose of 2.5 to 5.0 mg without the need for blood product or recombinant factor VII administration. [230] , [232]

• Recommendation • 6.1. In patients who are receiving VKAs and require reversal of the anticoagulant effect for an urgent surgical or other invasive procedure, we suggest treatment with

low-dose (2.5 to 5.0 mg) IV or oral vitamin K (Grade 1C). For more immediate reversal of the anticoagulant effect, we suggest treatment with fresh-frozen plasma or another prothrombin concentrate in addition to low-dose IV or oral vitamin K (Grade 2C).

• 6.2 Patients Who Are Receiving Antiplatelet Drugs • There is no pharmacologic agent that can reverse the antithrombotic effect of aspirin, clopidogrel, or ticlopidine, which irreversibly inhibit platelet function. Consequently,

patients who require an urgent surgical or other invasive procedure that requires normalized platelet function may receive transfused platelets, which would not be affected by prior administration of antiplatelet drugs.[233] However, the efficacy and safety of platelet transfusion in patients who are not thrombocytopenic and who require an urgent surgical or other invasive procedure are not known. One randomized trial in 11 healthy volunteers who received aspirin (325 mg loading dose, 81 mg maintenance dose) and clopidogrel (300-mg or 600-mg loading dose, 75-mg maintenance dose) found that subsequent transfusion of 12.5 U platelets led to normalized platelet function as determined by platelet function assays.[234] However, studies to assess the efficacy and safety of a platelet transfusion to neutralize the antiplatelet effects of aspirin or clopidogrel in the perioperative setting are lacking. Until such studies are done, it is reasonable to limit platelet transfusion to those patients who have excessive or life-threatening bleeding in the perioperative period.

• Potential alternatives to platelet transfusion in patients who have been exposed to antiplatelet drugs are prohemostatic agents. These include ɛ-aminocaproic acid and tranexamic acid, which are antifibrinolytic agents, and 1-deamino-8-D-arginine vasopressin, which increases plasma levels of von Willebrand factor and associated coagulation factor VIII. These agents may improve platelet function in patients who have been exposed to antiplatelet drugs. [235] However, outside of the setting of cardiac surgery, these drugs have not been widely studied [113] , [236] and should be limited to patients who have excessive or life-threatening perioperative bleeding because of potential prothrombotic effects.

• Recommendation • 6.2. For patients receiving aspirin, clopidogrel, or both, are undergoing surgery and have excessive or life-threatening perioperative bleeding, we suggest transfusion of

platelets or administration of other prohemostatic agents (Grade 2C).

Chest. 2008 Jun;133(6 Suppl):299S-339S.The perioperative management of antithrombotic therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition).

Douketis JD, Berger PB, Dunn AS, Jaffer AK, Spyropoulos AC, Becker RC, Ansell J; American College of Chest Physicians.

5.3.2 Patients Who Are Receiving Antiplatelet Drugs

• 5.3.2 Patients Who Are Receiving Antiplatelet Drugs • A prospective cohort study assessing patients who underwent cataract surgery found no

important increase in arterial thromboembolic events in 977 patients who interrupted aspirin compared to 3,363 patients who continued aspirin (0.20% vs 0.65%).[221] In these patients, there were no major or clinically relevant nonmajor bleeds and marginally higher clinically relevant nonmajor bleeds in patients who continued aspirin (0.06% vs 0%). Other studies reported similar results in patients undergoing cataract or vitreoretinal surgery. [222] , [223]

• There are few data in regard to the safety of continuing clopidogrel in patients undergoing ophthalmologic surgery. One study of patients undergoing cataract surgery found that although subconjunctival hemorrhage was more common in patients who were receiving either clopidogrel or warfarin than aspirin or no antithrombotic drugs, there were no sight-threatening bleeding complications.[227] One study described a patient who was receiving aspirin and clopidogrel and underwent an intracapsular extraction and anterior vitrectomy in whom the postoperative course was complicated by extensive hyphema and vitreous hemorrhage that cleared within 3 months.[228] As with other minor procedures, perioperative management will be driven by thromboembolic risk.

Recommendations of American College of Chest Physicians Evidence-Based Clinical Practice

Guidelines (8th Edition). 2008

• 5.3. In patients who are undergoing cataract removal and are receiving VKAs, we recommend continuing VKAs around the time of the procedure (Grade 1C).

• In patients who are undergoing cataract removal and are receiving aspirin, we recommend continuing aspirin around the time of the procedure (Grade 1C).

• In patients who are undergoing cataract removal and are receiving clopidogrel, please refer to the recommendations outlined in Section 4.5 and Section 4.6.

Ann Fr Anesth Reanim. 2010 Dec;29(12):878-83. Epub 2010 Nov 26.[Safety of "needle" regional anaesthesia for anterior segment surgery under antiplatelet agents and anticoagulants therapies].

Saumier N, Lorne E, Dermigny F, Walkzak K, Daelman F, Jezraoui P, Mahjoub Y, Milazzo S, Dupont H.

• Pôle d'anesthésie-réanimation, centre hospitalier universitaire d'Amiens, université Jules-Verne-de-Picardie, avenue René-Laennec, 80054 Amiens cedex, France.

• Abstract• INTRODUCTION: cataracts preferentially affect the elderly. More than 560,000 procedures are performed annually in France

on vulnerable patients that are exposed to cardio-circulatory conditions requiring antiplatelet and/or anticoagulants. Haemorrhagic complications resulting from cataract surgery and/or eye regional anaesthesia are rare but can lead to serious damage to eye function.

• PATIENTS AND METHODS: in this study, we compared the management care of two types of antiplatelet and/or anticoagulants successively utilizing the following procedure: first, the cessation of antiplatelet agents and anticoagulants were relayed with rapid elimination agents (constituting our reference "before" cohort [November 2004-May 2005]), then the antiplatelet or anticoagulant management was continued without stint according to recent data from literature (constituting our "after" cohort (April 2007-March 2008)).

• RESULTS: a reference population, consisting of 229 patients, was operated on exclusively with "surgical" sub-Tenon's anaesthesia. A second group, consisting of 178 patients, was operated on using "needle" regional anaesthesia. In both populations, nearly 33% of patients received antiplatelet or anticoagulant treatment. The incidence of subconjonctival haemorrhage occurred more frequently when anticoagulants agents were relayed (33% vs 0%; P<0,05), but there was no significant difference with antiplatelet agents (23% vs 8%; NS). The most common non-bleeding event was Chemosis and related to the type of anaesthetic technique utilized, although not serious it tended to jeopardize surgical comfort (anticoagulants: 35% vs 36% (NS), antiplatelet agents: 38% vs 40%; NS).

• CONCLUSION: the technical changes do not explain fully that occurrence of the HSC, in patients under anticoagulant treatment, decreased in the second period. The achievement of "needle" regional anaesthesia in the anterior segment eye surgery is a safe technique that does not require stopping antiplatelet treatment or anticoagulation

Kobayashi. H.Evaluation of the need to discontinue antiplatelet and anticoagulant medications before cataract

surgery. J Cataract Refract Surg. 2010 Jul;36(7):1115-9.

• Department of Ophthalmology, Kanmon Medical Center, Shimonoseki, Japan. kobi@earth.ocn.ne.jp• Abstract• PURPOSE: To assess the risk for intraoperative and postoperative bleeding associated with antiplatelet and/or

anticoagulant treatment in patients having uneventful phacoemulsification.• SETTING: Kokura Memorial Hospital, Kitakyusyu, Japan.• METHODS: In a nonrandomized case series, consecutive patients had phacoemulsification and intraocular lens

implantation under sub-Tenon anesthesia. All patients were on warfarin, acetylsalicylic acid (aspirin) therapy, or both. Patients discontinued therapy 1 week before surgery (discontinuation group) or continued the therapeutic regimen until the time of surgery (maintenance group).

• RESULTS: The discontinuation group comprised 182 patients and the maintenance group, 173 patients. There was no significant difference between the 2 groups in the mean prothrombin time-international normalized ratio in patients taking warfarin (P = .6). Although there was no significant intraoperative bleeding in any case, 47 eyes (16.5%) in the maintenance group and 31 eyes (10.8%) in the discontinuation group had a subconjunctival hemorrhage postoperatively (P = .0309). Minor postoperative ocular bleeding occurred in 11 eyes (4.0%) in the maintenance group and 7 eyes (2.5%) in the discontinuation group (P = .4). During the 1-month postoperative period, the mean change in corrected distance visual acuity was -0.462 logMAR +/- 0.331 (SD) in the maintenance group and -0.434 +/- 0.318 logMAR in the discontinuation group (P = .3).

• CONCLUSIONS: Patients taking warfarin, aspirin, or both up to the time of phacoemulsification had a significantly higher incidence of subconjunctival hemorrhage than those who discontinued therapy. There was no significant difference between the 2 groups in the incidence of intraoperative and postoperative complications or in visual improvement

J Cataract Refract Surg. 2011 Aug;37(8):1434-8.Risk assessment of simple phacoemulsification in patients on combined anticoagulant and antiplatelet

therapy.Barequet IS, Sachs D, Shenkman B, Priel A, Wasserzug Y, Budnik I, Moisseiev J, Salomon O.

Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Sackler Faculty of Medicine, Tel Aviv University, Tel Hashomer, Israel. ibarequet@hotmail.com

To assess the safety of phacoemulsification cataract extraction in patients on combined anticoagulant and antiplatelet treatment.Prospective interventional case series.: Consecutive patients with simple cataract on combined anticoagulant (warfarin) and antiplatelet (aspirin or clopidogrel) treatment who were unable to discontinue the treatment because of a high risk for thromboembolic events were included. Patients had cataract extraction under topical anesthesia with a clear corneal incision (CCI), phacoemulsification, and implantation of a foldable posterior chamber intraocular lens. Prothrombin time-international normalized ratio and platelet functions were evaluated immediately before surgery. Patients were also examined 1 day and 7 days postoperatively. Intraoperative and postoperative ocular bleeding and other related complications were assessed.RESULTS: 40 patients (51 eyes) with a mean age of 72 years (range 51 to 90 years) had phacoemulsification. Hemorrhagic complications were not observed at surgery or during the 1-week follow-up. Surgical complications included 1 rupture of the capsulorhexis and 1 implantation of a capsular tension ring due to partial zonulysis. No patient had a thromboembolic event.• CONCLUSIONS: In patients with uncomplicated cataract at high risk for thromboembolic events,

phacoemulsification cataract surgery using a CCI under topical needle-free anesthesia was safely performed without discontinuing systemic anticoagulant and antiplatelet treatment

Eur J Anaesthesiol. 2013 Aug;30(8):449-54. Management of antithrombotic therapies in patients scheduled for eye surgery.Bonhomme F, Hafezi F, Boehlen F,

Habre W.

• The large majority of patients undergoing ophthalmic surgery are elderly and take systemic medications on a regular basis, including antiplatelet and anticoagulant treatments. It is current practice for many physicians to discontinue antithrombotic treatment prior to surgery to reduce bleeding complications that may lead to retrobulbar haemorrhage and, ultimately, to loss of vision. However, discontinuation of antithrombotic treatment in such patients may lead to thromboembolic events with serious consequences. The present narrative review highlights the risk of thrombosis when discontinuing antithrombotic drugs and the risk of bleeding when continuing them. The published literature on this topic shows that discontinuation of antiplatelet or anticoagulant treatment leads to a substantially increased risk of arterial or venous thromboembolic events and related complications, especially in patients with atrial fibrillation, prosthetic heart valves or recent coronary stenting. This risk is distinctly higher than the risk of significant local haemorrhage. Ophthalmic bleeding events reported in the literature are usually minor, without serious consequences, even if antiplatelet or anticoagulant treatments are continued, provided that the anticoagulation level is within the therapeutic range. Thus, the current data are in favour of maintaining antiplatelet and anticoagulant drugs for most ophthalmic procedures, regardless of the anaesthetic techniques.

Risks and benefits of anticoagulant and antiplatelet medication use before cataract surgery

Study Operations number Aspirin warfarin

Conclusion

Katz 2003 19,283 4588 752 No dif cont vs noncont.

Benzimra 2008

55,567 9101 1525 Clopidogrel (524 pts)more local risk

Kobayashi 182+173 Subconjunct haemorr higher in the maintenance group

Saumier 229 vs 178 33% /// + Subconjunct haemorr (poor stat!!)

Barequet 40 all all 2 minor Ko

Hall* 49 no all Hyphema 3(6%)

Gainey * 9 no all 2 KO,1 rehospitalization

Roberts * 35 si si 1 retrobulbar hemorrhage

Robinson & *Nylander

10 no si 3 hyphema( 1 pt with INR 4.7)

McMahon * 28 no si 3 hyphema

*Arch Intern Med 2003;163:901-8

Perioperative management of patients receiving oral anticoagulants

Dunn,AS,Turpie,AGG.

Casi non sempre scorporati sec.la terapia

Unstable coronary artery disease (CAD) or uncontrolledhypertension.

• In general, surgery should be delayed in these circumstances until a cardiologist and (or) an anesthesiologist has determined that the risk profile has returned to normal. If surgery cannot be delayed (e.g., for sight-threatening phakolytic glaucoma in a monocular patient), monitoring of oxygen saturation, blood pressure, heart rate, and electrocardiogram by dedicated operating room personnel with IV access, advanced cardiac life support certification, IV medication injection ability, and with access to an anesthesiologist are needed.

COPD.

• • Oxygen dependency must be maintained intraoperatively.

• CO2-dependent breathers may do better with room air and drapes off the face.

• When cautery is used, the oxygen-enriched tmosphere beneath a closed, nonscavenged drape is a potential fire hazard. Lifting the edge of the drape or using a scavenger system is recommended if cautery is to be used.

Tamsulosin HCl, alfuzosin HCl, and other alpha1-adrenergic blocking agents may lead to IFIS

• • Once the patient has been identified as a user, special surgical measures might be taken. Stopping these medications does not seem to reduce the risk of IFIS and may aggravate urinary obstructive problems.

• Farmaci in Italia: alfuzosina,doxazosin,indoramina,prazosin,tamsulosina,terazosina(nomi commerciali: Mittoval,Xatral,Benur,Omnic,Pradif,Prostatil,Terafluss,Teraprost,Unoprost,Urodie,Lura,Botam,Tamlic,ecc Tamsulosin:Botam;Lura,Omnic,Pradif,Tamlic,Tamsulosin,Tamsulosina– Alfuzosin:Mittoval,Xatral

• “Caine” allergies. • Local anesthetics are either esters of benzoic and aminobenzoic

derivatives (e.g., cocaine,benzocaine, procaine, tetracaine, butacaine) or amidederivatives of xylidine and toluidine groups (e.g., lidocaine, mepivicaine, prilocaine).

• Skin testing for amide and ester local anesthetics can include preservative-freelidocaine, which may identify patients allergic to the preservatives in amide anesthetics.( Methylparaben)

STREETH CLOTHES

Street clothes• Many facilities allow patients to wear select items of

personal clothing to preserve their dignity. No research has been published comparing field contamination or infection rates with and without personal clothing. The Operating Room Nurses Association of Canada recommends that “for outpatient surgery, patients may wear some of their own clothing, especially if the clothing does not interfere with the procedure and the procedure is short (e.g.,cataract surgery). However, patients should still have their hair covered and be covered with clean linens.”

Footwear practices and operating room contamination

• Nurs Res. 1987 Nov-Dec;36(6):366-9.• Footwear practices and operating room contamination.• Copp G1, Slezak L, Dudley N, Mailhot CB.• Author information

• Abstract• The extent of bacterial transfer into the clean confines of the operating room (OR) was studied by

comparing the use of protective footwear (i.e., polypropylene shoe covers and OR restricted shoes) with unprotected street shoes over a 5-week period. The study was divided into two experimental times: (a) early morning (disinfected floor) and (b) midmorning (dirty floor). Data obtained from the early morning experiment showed that OR restricted shoes and shoe covers transferred fewer bacteria onto the disinfected study area than unprotected street shoes; similar findings were obtained from the midmorning experiment for shoe covers, but not for OR restricted shoes. A comparison of changes in bacterial counts obtained from OR restricted shoes and shoe covers worn from the changing room through a common corridor to the disinfected study area did not differ significantly from OR restricted shoes and shoe covers that were put on immediately before walking through the study area at both experimental times. Overall results indicated that protective footwear may act to reduce bacterial contamination on OR floors

Supporting the clothes change....• Ugeskr Laeger. 2009 Feb 2;171(6):420-3.• [Dispersal of Staphylococcus aureus from nasal carriers].• [Article in Danish]• Iskandar A1, Nguyen N, Kolmos HJ.• Author information

• Abstract• INTRODUCTION:• Staphylococcus aureus (Sa) is an important cause of hospital-acquired infections, and nasal carriage of Sa is common among health care

workers. This study was designed to measure the airborne dispersal of Sa and other bacteria from such carriers and to investigate whether the use of cap, gown, gloves, and mask could reduce this dispersal.

• MATERIAL AND METHODS:• A total of 13 nasal Sa carriers were identified among 63 persons screened for Sa nasal carriage. The volunteers were studied for airborne

dispersal of Sa in four different situations: quiet breathing, movements of the arms, whispering and loud talking. These activities were performed with and without gown, gloves, mask and cap upon street clothes.

• RESULTS:• The study showed that the highest number of Sa and bacteria in total was dispersed into the air when the volunteers were moving and

wearing only their street clothes. The dispersal of Sa into the air was reduced into a minimum by wearing cap, gown and gloves, and no further significant decrease was achieved by wearing a mask. This applied for all volunteers except for one, who had to wear a mask in order to reduce his dispersal of Sa to a minimum. The total dispersal of bacteria was significantly reduced by wearing cap, gown and gloves; however, to reduce this dispersal to a minimum, volunteers also had to wear a mask.

• CONCLUSION:• Our study supports the rational basis that gown, cap, gloves and mask should be used not only in the operating theatre, but also while e.g.

inserting central venous catheters.

Patients opinion about surgical attire:• Am J Surg. 2012 Nov;204(5):663-5. doi: 10.1016/j.amjsurg.2009.09.001. Epub 2010 Jun 29.• Patient attitudes to surgeons' attire in an outpatient clinic setting: substance over style.• Edwards RD1, Saladyga AT, Schriver JP, Davis KG.• Author information

• Abstract• BACKGROUND:• It is believed that patients prefer that surgeons convey a professional appearance with traditional business attire and white

laboratory coat. We performed a prospective study to assess patient opinions regarding traditional attire versus the wearing surgical scrubs in the outpatient setting.

• METHODS:• During a 5-month period, surgeons alternated wearing traditional clothing and surgical scrubs. Adult patients were given a

questionnaire assessing their preferences regarding surgeons' clothing.• RESULTS:• Six hundred twelve patients returned the questionnaire. The majority felt that scrubs were appropriate attire for physicians.

Half of the patients felt that wearing white laboratory coats is necessary. A minority felt that their surgeon's dress affects their opinion regarding the care they received. There was no difference between responses regardless of the attire actually worn.

• CONCLUSIONS:• Surgeon's clothing choice does not significantly influence patient's opinion of the care they receive. Patients do not have

strong preferences for white coats or more traditional surgical attire

Recentemente(genn 2014) sulla rivistina “Outpatient surgery”....un sondaggio di opinioni :8:1 per i mantenimento

vestiario,ma copertura con gown ,cappello,telo..• We are a newly opened ASC doing ophthalmology procedures. The patients remain in street clothes that are

covered with a hospital gown, shoe covers and bouffant cap for transport into the OR. I have been told that we do much more than other ASCs by using the gown and shoe covers and have been asked to stop this practice. I would like to hear what other ASCs require?

• Cathy Summers (Administrator/Director/Manager/Owner/Executive Officer) at January 10, 2014 (3:57 pm)• We are a four OR ophthalmology ambulatory facility. Our patients are provided a bouffant cap, shoe covers, a

paper "johnny coat" to place over their clothes, and shoe covers.• Mary Craddock (Administrator/Director/Manager/Owner/Exec. Officer) at January 13, 2014 (2:44 pm)• We have a cataract/eye procedure specific O.R., where no other procedures are performed. Our cataract/eye

patients are brought from the pre-op holding area to the cataract room on a gurney, fully clothed -- no shoe covers, no hats, and covered in a warmed blanket (for their comfort, not for infection control). Also, the room does not enter/exit into a sub-sterile room like our other O.R.'s, and does not have luminar air flow. We have little to no infections.

• Terrolynn G. (Other) at January 13, 2014 (2:12 pm)• We are a multi-specialty clinic and we allow the patient to leave on their pants (jeans,etc). Woman are allowed to

also leave on their bras and we give each patient a gown, cap and shoes covers. Shoes are removed and placed in bags with all other belongings. Patient is allowed to leave on their socks. Each patient gets a blanket and placed on a gurney. We have had no issues of infection.

• Linda Lewis (Director, Surgical Services/Director of Nursing) at January 13, 2014 (1:52 pm)• Our patients remove their top, wear shoe covers and a bouffant cap.Andrea Hyatt• Andrea Hyatt (Administrator/Director/Manager/Owner/Executive Officer) at January 13, 2014 (1:15 pm)• Our patients leave on their clothing. We have them wear a bouffant cap, shoe covers, and they are covered with

a blanket. We do almost all ophthalmology procedures and this seems to work well for us.• Heather Barbish (Other) at January 13, 2014 (1:11 pm)• Our patients leave on their clothing. We have patients wear shoe covers and a hat cover. They are covered with a

blanket. We only do Ophthalmology procedures and the patients are very grateful they don't need to get undressed.

• Rita Keating (Director, Surgical Services/Director of Nursing) at January 13, 2014 (12:43 pm)• At least put shoe covers and hair covers on the patients. Blankets often don't cover the shoes. I have seen some

filthy dirty mud caked shoes, leaving dirt on the cataract gurneys.• Brian Murray (Administrator/Director/Manager/Owner/Executive Officer) at January 13, 2014 (12:32 pm)• We are a cataract facility. Our patients remain in street clothes, wear a bouffant cap and are covered fully by a

blanket.• M. SMITH (Director, Surgical Services/Director of Nursing) at January 13, 2014 (12:09 pm)• We have patient to remove top and wear hospital gown mainly to prevent any prep from getting on their clothes

and allow easy access for EKG electrodes. We do provide a surgical hat and cover them with a blanket and they stay on a special eye stretcher for the entire procedure. They are allowed to keep their other clothes and shoes on unless they are visably soiled. We have not seen any infections since changing to this practice for the past 4 years. I would also like to note that we did see a significant "decrease" in falls post op because patients were not trying to put their clothes back on while being a bit disoriented with an eye patch and possibly a little sedation still on board.

• James Brown (Administrator/Director/Manager/Owner/Exec. Officer) at January 14, 2014 (3:35 pm)• Surgical Hospital w/7 ORs w/2 dedicated to ophthalmology: We allow cataract patients to leave on pants, socks

and have them remove their upper clothing. Use a BairHugger gown and cover with a blanket and cap. We have had no increase in infection in ten years.

• Diane Crelia (Other) at January 14, 2014 (11:41 am)• We leave their clothes on, cover their hair and wrap in a blanket. ASC• Kathleen S. (OR Manager/Supervisor) at January 13, 2014 (9:31 pm)• Acute care Hospital: We allow cataract patients to leave on pants, socks and have them remove their tops (except

women's bras). Use a BairHugger gown and cover with a blanket, hat.Dee GilsonSurgical Services Manager• Dee Gilson (OR Manager/Supervisor) at January 13, 2014 (9:15 pm)• Ambulatory CenterOur cataract patients enter the OR suite fully clothed, surgical hat, and covered with a Bear

Hugger blanket.• Susan H. (Other) at January 13, 2014 (6:40 pm)• hospital setting: Patients remove top/wear gown and cap. Covered with blanket they transport from preop to OR

on gurney, which they remain on during the procedure. Lauri Rootvik Charge Nurse Same Day Surgery• lauri rootvik (Administrator/Director/Manager/Owner/Exec. Officer) at January 13, 2014 (6:04 pm)• We cover our patients hair with a cap and cover their clothes with a blanket once they are on the gurney.• Imelda Kelly (Administrator/Director/Manager/Owner/Exec. Officer) at January 13, 2014 (5:51 pm)• We are a three O.R. full service ophthalmic surgery center. Our cataract patients remain in their street clothes

(they are asked to wear button down shirts). We do have our patients wear shoe covers and bouffant caps, and blankets are provided. Sally Mashburn, M. D., Medical Director.

• Sally Mashburn (Medical Director/Chief Surgeon) at January 13, 2014 (2:59 pm)

Patient allergic to Xr contrast media

• “Little evidence exists that elemental iodine is responsible for idiosyncratic contrast reactions or povidone-iodine dermatitis and no evidence exists that it is involved in seafood allergy. The notion that iodine confers specific cross-reactivity between these agents is unfounded.”82 In patients with povidone-iodine dermatitis, an alternative skin preparation solution with a nonalcohol, aqueous-based chlorhexidine skin preparation and conjunctival antibiotic prophylaxis should be considered. In patients with iodine, IVP dye, or seafood allergies, the evidence supports the use of povidone-iodine for skin preparation. The use of sterile 5% povidone-iodine in the conjunctival sac is also supported for patients reporting these allergies. There is no reported safety profile for its use in the conjunctival sac in the presence of skin allergy to povidone-iodine.

["Iodine allergy": point of view]. [Dewachter P, Tréchot P, Mouton-Faivre C. Ann Fr Anesth Reanim. 2005

Jan;24(1):40-52

• Source

• Service d'anesthésie-réanimation chirurgicale, CHU, hôpital central, 29, avenue du Maréchal-de-Lattre-de-Tassigny, 54035 Nancy cedex, France. pascale.dewachter@wanadoo.fr

• Abstract

• OBJECTIVE:

• The aim of this literature review is to suggest a diagnostic and a preventive attitude in patients having presented an immediate hypersensitivity reaction due to an iodinated drug.

• DATA SOURCES:

• Literature review. Data were searched in the Medline database from 1967 to 2004 in English and French language. Complementary references were selected from the bibliography of selected references or from authors' personal databases. The following key-words were used separately or combined: Hypersensitivity, Immediate; Allergy; Contrast Media; Povidone-Iodine; Iodine; Iodine Compounds; Iodides; Amiodarone; Seafood, Parvalbumins; Tropomyosin.

• STUDY SELECTION:

• Randomized studies, epidemiological studies, original articles, clinical cases, and letters to the editor were selected.

• DATA SYNTHESIS:

• The implication of iodine has never been demonstrated during allergic hypersensitivity reactions due to iodinated drugs. However, IgE-mediated allergic hypersensitivity reactions have been published with contrast media or iodinated antiseptics and will be described in this development. In a wider sense, allergic hypersensitivity reactions due to seafood are evoked because often improperly considered as a risk factor of allergic reaction to iodinated drugs. The allergenic determinant responsible of patient sensitization is not known for iodinated contrast media, but is probably due to povidone in case of iodine povidone. In fish, the allergen is described as the protein M. There has also been strong immunological evidence that tropomyosin is a cross-reactive allergen among crustaceans and molluscs (shellfishs). In case of hypersensitivity reaction occurring with iodinated drug, an allergological assessment is required to confirm the immune mechanism, to identify the culprit drug or substance and to identify cross-reactivity especially with iodinated contrast media.

• CONCLUSION:

• Asking a patient if he/she is "allergic to iodine" is a question that should be avoided because its significance is null. A diagnosis of drug allergy, essentially relying on clinical symptoms, biological tests and cutaneous tests, is required to take adequate preventive measures

Dewachter, Pascale a; Mouton-Faivre, Claudie b; Castells, Mariana C c; Hepner, David L dAnesthesia in the patient with multiple drug allergies: are all allergies the same?Current Opinion in Anaesthesiology. 24(3):320-325, June

2011.

• Povidone iodine• Povidone iodine is a stable iodophor solution containing a water-soluble

complex of iodine and polyvinylpyrrolidone (PVP). PVP is a water-soluble polymer made from the monomer N-vinylpyrrolidone, which has been identified as the allergenic determinant by skin testing and immunoassays [31]. Less than 10 documented IgEmediated allergic reactions have been reported following povidone iodine. Clinical features of these reactions are moderate and observed following topical, vaginal or rectal applications. The allergenic determinant of povidone iodine in cases of immediate hypersensitivity is povidone. There are no data to support potential cross-reactivity between shellfish and povidone iodine. Therefore, the only contraindication to povidone iodine is a previous documented hypersensitivity reaction to this antiseptic.

• .

Iodinated contrast agents

• All the currently available iodinated contrast media (ICM) are chemical modifications of a 2,4,6-tri-iodinated benzene ring [32]. Although the allergenic determinant remains unknown, it is not the iodine atom. Crossreactivity among the different ICM seems to be low despite their closely related molecular structures, but should be assessed through skin tests in order to identify safe alternative regimens [32]. Patients with a previous documented IgE-mediated hypersensitivity to an ICM

• have been safely injected during subsequent radiological procedures with another ICM that was negative by skin

• testing [33]. In addition, there is no role to contraindicate the use of povidone iodine in patients allergic to ICM

BMJ. 2006 Sep 30;333(7570):675. Pharmacological prevention of serious anaphylactic reactions due to iodinated contrast media: systematic review.Tramèr MR, von Elm E, Loubeyre P, Hauser C.

• Systematic search (multiple databases, bibliographies, all languages, to October 2005) for randomised comparisons of pretreatment with placebo or no treatment (control) in patients receiving iodinated contrast media. Review methods Trial quality was assessed by all investigators. Information on trial design, population, interventions, and outcomes was abstracted by one investigator and cross checked by the others. Data were combined by using Peto odds ratios with 95% confidence intervals.

• RESULTS:

• Nine trials (1975-96, 10 011 adults) tested H1 antihistamines, corticosteroids, and an H1-H2 combination. No trial included exclusively patients with a history of allergic reactions. Many outcomes were not allergy related, and only a few were potentially life threatening. No reports on death, cardiopulmonary resuscitation, irreversible neurological deficit, or prolonged hospital stays were found. In two trials, 3/778 (0.4%) patients who received oral methylprednisolone 2x32 mg or intravenous prednisolone 250 mg had laryngeal oedema compared with 11/769 (1.4%) controls (odds ratio 0.31, 95% confidence interval 0.11 to 0.88). In two trials, 7/3093 (0.2%) patients who received oral methylprednisolone 2x32 mg had a composite outcome (including shock, bronchospasm, and laryngospasm) compared with 20/2178 (0.9%) controls (odds ratio 0.28, 0.13 to 0.60). In one trial, 1/196 (0.5%) patients who received intravenous clemastine 0.03 mg/kg and cimetidine 2-5 mg/kg had angio-oedema compared with 8/194 (4.1%) controls (odds ratio 0.20, 0.05 to 0.76).

• CONCLUSIONS:

• Life threatening anaphylactic reactions due to iodinated contrast media are rare. In unselected patients, the usefulness of premedication is doubtful, as a large number of patients need to receive premedication to prevent one potentially serious reaction. Data supporting the use of premedication in patients with a history of allergic reactions are lacking. Physicians who are dealing with these patients should not rely on the efficacy of premedication

Factors Lowering IOP

• Drop in B.P, reduces choroidal volume.• Relaxation of extraocular muscles lowers

wall• tension.• Pupillary constriction facilitates aqueous• outflow.• Mild hypocapnia (26 – 30 mmHg) reduces• choroidal blood volume

• Can J Anaesth. 2010 Jun;57(6):602-17.• Anesthetic management for pediatric strabismus surgery: Continuing professional development.• Rodgers A, Cox RG.• Department of Anesthesia, University of Calgary, AB, Canada. aerodgers@hotmail.com <aerodgers@hotmail.com>• Abstract• PURPOSE: Strabismus surgery is one of the most common pediatric ophthalmic procedures. The purpose of this

continuing professional development module is to update physicians on the anesthetic considerations of pediatric patients undergoing strabismus surgery.

• PRINCIPAL FINDINGS: The preoperative assessment is important, as patients undergoing strabismus surgery may have an associated neuromuscular disorder, congenital syndrome, or cardiac disease. Malignant hyperthermia is no longer considered as being an issue associated with strabismus. The laryngeal mask airway is used frequently and has been shown as being associated with a low incidence of complications in strabismus surgery. The anesthesia technique can be adapted to decrease the incidence of the oculocardiac reflex and the oculorespiratory reflex, and the use of anticholinergic prophylaxis remains debatable. Since patients are at high risk for postoperative nausea and vomiting (PONV), combination anti-emetic therapy is recommended using dexamethasone and ondansetron. Metoclopramide was not found to provide additional benefit when combined with other anti-emetics. Droperidol is effective, but there remains a black box warning for dysrhythmias. Effective analgesics in this patient population include acetaminophen, nonsteroidal anti-inflammatory drugs, peribulbar blocks, and subtenon blocks. Topical tetracaine drops have demonstrated mixed results, and topical nonsteroidal anti-inflammatory drops were found not to be effective. The use of opioids should be minimized due to the increased incidence of PONV

Sedation requirements • Sedation requirements (midaz 0.5 + fent 25 microgr pca)were similar for cataract surgery

under topical and retrobulbar anesthesia. Eur J Ophthalmol. 2004 Nov-Dec;14(6):473-7. Comparison of sedation requirements for cataract surgery under topical anesthesia or retrobulbar block.Balkan BK, Iyilikçi L, Günenç F, Uzümlü H, Kara HC, Celik L, Durak I, Gökel E.

• Subjects tended to prefer block to topical anaesthesia and oral to intravenous sedation. On a scale from 0 to 100, subjects preferred oral to intravenous sedation and block to topical anaesthesia by about 8 points. Br J Ophthalmol. 2004 March; 88(3): 333–335. Patient preferences for anaesthesia management during cataract surgery D S Friedman,S W Reeves,E B Bass,L H Lubomski,L A Fleisher, O D Schein

• Midaz 0.015 mg/kg (0.03-0.04 recommended dose….)did not influence anxiety levels (Stai) and pain under topical anesth. : J Cataract Refract Surg. 2004 Feb;30(2):437-43. Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesia.Habib NE, Mandour NM, Balmer HG.

• Maintaining communication with the patient;voice,electronic devices… : Eye. 2004 Feb;18(2):147-

51. Patient communication during cataract surgery.Mokashi A, Leatherbarrow B, Kincey J, Slater R, Hillier V, Mayer S.• the addition of ketamine (13.2 +/- 3.3 mg) to propofol (44 +/- 11 mg) decreased the

hypnotic requirement and improved the quality of sedation without prolonging recovery.Anesth Analg. 1999 Aug;89(2):317-21. Propofol versus propofol-ketamine sedation for retrobulbar nerve block: comparison of sedation quality, intraocular pressure changes, and recovery profiles. Frey K, Sukhani R, Pawlowski J, Pappas AL, Mikat-Stevens M, Slogoff S.

Sedation requirements 2

• dexmedetomidine> saline Eur J Ophthalmol. 2008 May-Jun;18(3):361-7. Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedation.Erdurmus M, Aydin B, Usta B, Yagci R, Gozdemir M, Totan Y.

• Alfentanil titrated + methoexital,5168 pts,no problems…Rand Eye Institute, Pompano Beach, Florida 33064, USA….Ophthalmology. 2000 May;107(5):889-95..Rand-Stein analgesia protocol for cataract surgery.Rand WJ, Stein SC, Velazquez GE.

• .• The effect of combined topical-intracameral anaesthesia on neuroleptic

requirements during cataract surgery. Can J Ophthalmol. 2010 Feb;45(1):52-7 .Ho AL,

Zakrzewski PA, Braga-Mele R.– the addition of intracameral lidocaine to topical anaesthesia during cataract surgery

leads to a decrease in the administration of intraoperative fentanyl,not midazolam• Ecc,ecc.

• Ophthalmology. 2000 May;107(5):889-95.• Rand-Stein analgesia protocol for cataract surgery.• Rand WJ, Stein SC, Velazquez GE.• Rand Eye Institute, Pompano Beach, Florida 33064, USA.• Abstract• OBJECTIVE: To describe the safety and efficacy of an analgesia protocol that enables the surgeon to maintain

control over an alert patient experiencing seemingly painless ambulatory cataract surgery, while eliminating the risks and side effects associated with general, local, topical, and intracameral anesthesia. DESIGN: Noncomparative, interventional case series. PARTICIPANTS: Five thousand one hundred sixty-eight consecutive cataract surgery cases operated on by the same surgeon from April 1, 1993 through June 1, 1998. METHODS: This technique produces profound ocular analgesia, avoiding any undesired sedative effects, using very low-dose, titrated, intravenous alfentanil. Complete control of the uncooperative patient, including lid squeezing and ocular and general body movements, is obtainable whenever necessary using very low-dose, titrated, intravenous methohexital. MAIN OUTCOME MEASURES: Success was defined as surgery completed in a controlled manner without the need to convert to general, local, topical, or intracameral anesthesia and the patient's experience being perceived as pain free. RESULTS: One hundred percent of the cases were successful without ever deviating from the protocol. CONCLUSIONS: This analgesia protocol offers advantages for cataract surgery. It virtually eliminates the morbidity of cataract surgery associated with other anesthesia techniques while providing excellent and reliable control. It allows for an immediate postoperative recovery with instantaneous vision restoration. These patients are generally awake, alert, and retain their protective reflexes

• J Cataract Refract Surg. 2004 Feb;30(2):437-43.• Effect of midazolam on anxiety level and pain perception in cataract surgery with topical anesthesia.• Habib NE, Mandour NM, Balmer HG.• Royal Eye Infirmary, Plymouth, England. nabil.habib@phnt.swest.nhs.uk• Abstract• PURPOSE: To study the effect of sedation on patients' anxiety level and perception of pain during cataract surgery

under topical anesthesia. SETTING: Royal Eye Infirmary, Plymouth, England. METHODS: This prospective controlled double-blind clinical trial comprised 100 consecutive patients having routine phacoemulsification with posterior chamber intraocular lens implantation under topical anesthesia by a single experienced surgeon. Patients were randomized to receive intravenous midazolam (0.015 mg/kg body weight) 15 minutes before surgery or no sedation. The main evaluation criteria were the anxiety based on the 6-item, short form of the State-Trait Anxiety Inventory, the pain score using a visual analog scale, and overall patient satisfaction. RESULTS: All operations were uneventful, and no side effects were noted from the use of midazolam. Anxiety scores were significantly higher on arrival at the hospital than just before the commencement and after the conclusion of the surgery in both groups (P<.05). Patients were less anxious after administration of midazolam, but this did not achieve statistical significance. The mean pain score was 0.29 (range 0 to 4) in the sedation group and 0.38 (range 0 to 4) in the control group; the difference between groups was not statistically significant. The patients were equally satisfied in both groups, with mean scores of 3.84 (range 0 to 4) and 3.88 (range 2 to 4), respectively. CONCLUSIONS: Patients who had cataract surgery under topical anesthesia were highly satisfied with their operative experience and reported minimal pain during surgery. Anxiety levels diminished after arrival at the hospital, possibly because of reassurance by experienced staff. Intravenous midazolam did not seem to significantly reduce pain or anxiety

• Anaesthesist. 1992 Nov;41(11):673-9.• [Premedication in retrobulbar anesthesia. A blood gas analysis comparison of sublingual flunitrazepam and intravenous midazolam].• [Article in German]• Heinze J, Rohrbach M.• Klinik für Anästhesiologie, Universität Tübingen.• Abstract• Benzodiazepines for sedation may decrease the PaO2, the arterial O2 saturation (SaO2), and the CO2 response more in the elderly than in the young.

The purpose of this study was to assess changes in blood gases due to i.v. midazolam or sublingual flunitrazepam given as premedication in elderly patients for unilateral cataract surgery. METHODS. Fifty patients over 65 years of age with treated arterial hypertension and other co-existing diseases (ASA III-IV) were randomly assigned to have: (1) i.v. midazolam titrated until they became drowsy (17 patients; 2.85 +/- 0.84 mg [mean +/- SD]); (2) sublingual flunitrazepam (16 patients; 0.005 mg/kg); or (3) no sedation (17 patients; controls). On entering the operating theatre, the radial artery was cannulated and the first blood gas analysis was obtained. The premedication was then given. At 5, 10, 20, and 30 min after premedication, before and 10 min after retrobulbar block, before operation, 5 and 15 min after the beginning of the operation, 10 and 20 min after administration of 500 mg acetazolamide i.v. during the operation, and 10 and 20 min after the operation additional arterial blood samples were analysed (a total of 15 measuring points). Pulse oximetry, invasive blood pressure, and ECG were continuously monitored. All patients received oxygen 3 l/min during the operation by nasal cannula. Differences between the three groups were analysed by Student's t-test or U-test and a P value < 0.05 was considered significant. RESULTS. The patient demography, including duration of anaesthesia and operation, was similar in the three groups (Table 1). No significant differences were seen in heart rate, mean arterial pressure, PaO2, pulse-oximetric oxygen saturation (SpO2), base excess, or serum bicarbonate levels. The PaCO2 increased in patients after midazolam (P < 0.01) and flunitrazepam (P < 0.05) until the beginning of the operation compared with the control group (Fig. 3); 20 min after the operation there was still a significant difference between the midazolam group and the controls. SaO2 was significantly (P < 0.05) lower in the midazolam group 10 and 20 min after administration of premedication compared with the control group, but was within physiological limits (Fig. 5). Despite titration, 2 patients had severe respiratory insufficiency 3 min after midazolam: the SpO2 decreased below 85% and the paO2 below 55 mmHg. The paCO2 was higher (P < 0.05) in the midazolam group 10 min after acetazolamide compared with the controls. CONCLUSIONS. The results of the study show the potential hazards of i.v. midazolam in the elderly. If sedation is required for cataract surgery under local anaesthesia, we recommend sublingual flunitrazepam or the use of benzodiazepines with lower hypnogenic effects in the elderly. A thorough preoperative discussion of anaesthesia and the operation might be an adequate substitute for any premedication in high-risk patients; the best blood gas analysis results were obtained in the control group

Clin Ophthalmol. 2012;6:2075-9. Dexmedetomidine sedation in painful posterior segment surgery.Mansour A, Taha S.

• Author information

• Abstract• PURPOSE:• To present a case series on the use of dexmedetomidine (Precedex) sedation in painful posterior segment surgery performed under topical

anesthesia, similar to its use in cataract surgery.• METHODS:• A prospective review of cases that had posterior segment surgery under topical anesthesia and that needed sedation. Dexmedetomidine-loading

infusion was 1 mcg/kg over 10 minutes, followed by a maintenance infusion (0.5 mcg/kg/h).• RESULTS:• NINE PATIENTS WERE OPERATED ON UNDER TOPICAL ANESTHESIA: two scleral buckle, five cryopexy, one scleral laceration, and one pars plana

vitrectomy with very dense laser therapy in an albinotic fundus; six patients had retinal detachment. General or local anesthesia were not possible due to medical or ocular morbidities, use of anticoagulants, or the surgery plan changed intraoperatively when new pathologies were discovered. The surgeon achieved good surgical control in eight of nine cases, with one patient having ocular and bodily movements that were disturbing. Six patients had no pain, while three patients reported mild pain. No adverse effects were noted and all patients had successful surgical outcomes. Heart rate, blood pressure, and oxygen saturation were well controlled throughout the procedures. The most frequent adverse reactions of dexmedetomidine reported in the literature in less than 5% (hypotension, bradycardia, and dry mouth) were not recorded in the present study.

• CONCLUSION:• When a surgeon has planned to do a pars plana vitrectomy under topical anesthesia and the surgical situation dictates the addition of cryopexy,

scleral buckle, or intense laser retinopexy, then sedation with dexmedetomidine can help in the control of ocular pain in the majority of cases, with good intraoperative and immediate postoperative hemodynamic control with the possibility of supplemental rescue analgesia. Dexmedetomidine, a sedative analgesic, is devoid of respiratory depressant effects, and its use in posterior segment surgery under topical anesthesia is reported here for the first time.

• Free PMC

Circulation. 2012 Jul 17;126(3):343-8. Periprocedural bleeding and thromboembolic events with dabigatran compared with warfarin: results from the Randomized Evaluation

of Long-Term Anticoagulation Therapy (RE-LY) randomized trial.Healey JS, Eikelboom J, Douketis J, Wallentin L, Oldgren J, Yang S, Themeles E,

Heidbuchel H, Avezum A, Reilly P, Connolly SJ, Yusuf S, Ezekowitz M; RE-LY Investigators.Circulation. 2012 Sep 4;126(10):e160. Heidbuchle, Hein [corrected to Heidbuchel, Hein].• Dabigatran reduces ischemic stroke in comparison with warfarin; however, given the lack of antidote, there is concern that it might increase bleeding when surgery or

invasive procedures are required.• METHODS AND RESULTS:• The current analysis was undertaken to compare the periprocedural bleeding risk of patients in the Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY)

trial treated with dabigatran and warfarin. Bleeding rates were evaluated from 7 days before until 30 days after invasive procedures, considering only the first procedure for each patient. A total of 4591 patients underwent at least 1 invasive procedure: 24.7% of patients received dabigatran 110 mg, 25.4% received dabigatran 150 mg, and 25.9% received warfarin, P=0.34. Procedures included: pacemaker/defibrillator insertion (10.3%), dental procedures (10.0%), diagnostic procedures (10.0%), cataract removal (9.3%), colonoscopy (8.6%), and joint replacement (6.2%). Among patients assigned to either dabigatran dose, the last dose of study drug was given 49 (35-85) hours before the procedure on comparison with 114 (87-144) hours in patients receiving warfarin, P<0.001. There was no significant difference in the rates of periprocedural major bleeding between patients receiving dabigatran 110 mg (3.8%) or dabigatran 150 mg (5.1%) or warfarin (4.6%); dabigatran 110 mg versus warfarin: relative risk, 0.83; 95% CI, 0.59 to 1.17; P=0.28; dabigatran 150 mg versus warfarin: relative risk, 1.09; 95% CI, 0.80 to 1.49; P=0.58. Among patients having urgent surgery, major bleeding occurred in 17.8% with dabigatran 110 mg, 17.7% with dabigatran 150 mg, and 21.6% with warfarin: dabigatran 110 mg; relative risk, 0.82; 95% CI, 0.48 to 1.41; P=0.47; dabigatran 150 mg: relative risk, 0.82; 95% CI, 0.50 to 1.35; P=0.44.

• CONCLUSIONS:• Dabigatran and warfarin were associated with similar rates of periprocedural bleeding, including patients having urgent surgery. Dabigatran facilitated a shorter

interruption of oral anticoagulation.• CLINICAL TRIAL REGISTRATION:• URL: http://www.clinicaltrials.gov. Unique identifier: NCT00262600.• Comment in• Anticoagulation, novel agents, and procedures: can we pardon the interruption? [Circulation. 2012]•

Response to letters regarding article, “Periprocedural bleeding and thromboembolic events with dabigatran compared with warfarin: results from the Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) Randomized Trial”. [Circulation. 2013]

•Letter by David et al regarding article, "Periprocedural bleeding and thromboembolic events with dabigatran compared with warfarin: results from the Randomized Evaluation of Long-term Anticoagulation Therapy (RE-LY) Randomized Trial". [Circulation. 2013]

•Letter by Hjemdahl et al regarding article, "Periprocedural bleeding and thromboembolic events with dabigatran compared with warfarin: results from the Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) Randomized Trial". [Circulation. 2013]

• PMID: 22700854 [PubMed - indexed for MEDLINE] Free full text

• Circulation. 2013 Nov 19;128(21):2325-32. doi: 10.1161/CIRCULATIONAHA.113.002332. Epub 2013 Sep 30.• Management and outcomes of major bleeding during treatment with dabigatran or warfarin.• Majeed A, Hwang HG, Connolly SJ, Eikelboom JW, Ezekowitz MD, Wallentin L, Brueckmann M, Fraessdorf M, Yusuf S, Schulman S.• Author information

• Coagulation Unit, Hematology Center, Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden (A.M., S.S.); the Department of Medicine, Soonchunhyang University Gumi's Hospital, North Kyungsang Province, South Korea (H.-G-H.); McMaster University, Population Health Research Institute, Hamilton, ON, Canada (S.J.C., J.W.E., S.Y.); Lankenau Medical Center, Thomas Jefferson Medical College, Wynnewood, PA (M.D.E.); Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden (L.W.); Boehringer Ingelheim Pharma GmbH & Co KG, Ingelheim, Germany (M.B., M.F.); Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany (M.B.); and the Department of Medicine, McMaster University and Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada (S.S.).

• Abstract• BACKGROUND:• The aim of this study was to compare the management and prognosis of major bleeding in patients treated with dabigatran or warfarin.• METHODS AND RESULTS:• Two independent investigators reviewed bleeding reports from 1034 individuals with 1121 major bleeds enrolled in 5 phase III trials comparing dabigatran with

warfarin in 27 419 patients treated for 6 to 36 months. Patients with major bleeds on dabigatran (n=627 of 16 755) were older, had lower creatinine clearance, and more frequently used aspirin or non-steroid anti-inflammatory agents than those on warfarin (n=407 of 10 002). The 30-day mortality after the first major bleed tended to be lower in the dabigatran group (9.1%) than in the warfarin group (13.0%; pooled odds ratio, 0.68; 95% confidence interval, 0.46-1.01; P=0.057). After adjustment for sex, age, weight, renal function, and concomitant antithrombotic therapy, the pooled odds ratio for 30-day mortality with dabigatran versus warfarin was 0.66 (95% confidence interval, 0.44-1.00; P=0.051). Major bleeds in dabigatran patients were more frequently treated with blood transfusions (423/696, 61%) than bleeds in warfarin patients (175/425, 42%; P<0.001) but less frequently with plasma (dabigatran, 19.8%; warfarin, 30.2%; P<0.001). Patients who experienced a bleed had shorter stays in the intensive care unit if they had previously received dabigatran (mean 1.6 nights) compared with those who had received warfarin (mean 2.7 nights; P=0.01).

• CONCLUSIONS:• Patients who experienced major bleeding on dabigatran required more red cell transfusions but received less plasma, required a shorter stay in intensive care, and

had a trend to lower mortality compared with those who had major bleeding on warfarin.• CLINICAL TRIAL REGISTRATION URL:• http://www.ClinicalTrials.gov. Unique identifiers: NCT00262600, NCT00291330, NCT00680186, NCT00329238 and NCT00558259.

• Ann Intern Med. 2013 Aug 20;159(4):275-84. doi: 10.7326/0003-4819-159-4-201308200-00008.• Comparative effectiveness of new oral anticoagulants and standard thromboprophylaxis in patients having total hip or knee replacement: a systematic review.• Adam SS, McDuffie JR, Lachiewicz PF, Ortel TL, Williams JW Jr.• Abstract• BACKGROUND:• Pharmacologic thromboprophylaxis reduces the risk for venous thromboembolism after total hip replacement (THR) or total knee replacement (TKR). New oral

anticoagulants (NOACs), including direct thrombin inhibitors and factor Xa inhibitors, are emerging options for thromboprophylaxis after these procedures.• PURPOSE:• To compare the benefits and risks of NOACs versus standard thromboprophylaxis for adults having THR or TKR.• DATA SOURCES:• MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews from January 2009 through March 2013.• STUDY SELECTION:• English-language systematic reviews.• DATA EXTRACTION:• Two independent reviewers abstracted data and rated study quality and strength of evidence.• DATA SYNTHESIS:• Six good-quality systematic reviews compared NOACs with low-molecular-weight heparin (LMWH) for thromboprophylaxis after THR or TKR. Risk for symptomatic

deep venous thrombosis, but not risk for death or nonfatal pulmonary embolism, was reduced with factor Xa inhibitors compared with LMWH (4 fewer events per 1000 patients). Conversely, the risk for major bleeding increased (2 more events per 1000 patients). Outcomes of dabigatran did not significantly differ from those of LMWH. Indirect evaluation of NOACs by common comparison with LMWH showed nonsignificantly reduced risks for venous thromboembolism with rivaroxaban compared with dabigatran (risk ratio [RR], 0.68 [95% CI, 0.21 to 2.23]) and apixaban (RR, 0.59 [CI, 0.26 to 1.33]) but increased major bleeding. New oral anticoagulants have not been compared with warfarin, aspirin, or unfractionated heparin.

• LIMITATIONS:• Head-to-head comparisons among NOACs were not available. Efficacy is uncertain in routine clinical practice.• CONCLUSION:• New oral anticoagulants are effective for thromboprophylaxis after THR and TKR. Their clinical benefits over LMWH are marginal and offset by increased risk for major

bleeding.• PRIMARY FUNDING SOURCE:• U.S. Department of Veterans Affairs

Eye (Lond). 2009 Jan;23(1):10-6. Epub 2008 Feb 8.The Cataract National Dataset electronic multicentre audit of 55,567 operations: antiplatelet and anticoagulant medications.Benzimra JD, Johnston RL, Jaycock P,

Galloway PH, Lambert G, Chung AK, Eke T, Sparrow JM; EPR User Group.• Gloucestershire Eye Department, Cheltenham General Hospital, Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, Gloucestershire, UK.• Abstract• AIMS: This study aims to establish the prevalence of aspirin, dipyridamole, clopidogrel, and warfarin use in patients undergoing cataract surgery, and to compare local anaesthetic and intraoperative complication rates

between users and non-users.

• METHODS: The Cataract National Dataset was remotely extracted and anonymised on 55,567 operations at 12 NHS Trusts using electronic patient records (EPRs) between 2001 and 2006.

• RESULTS: This report analyses 48,862 of the 55,567 operations from the eight centres, which routinely recorded a drug history. In all, 28.1% of the 48,862 patients were taking aspirin, 5.1% warfarin, 1.9% clopidogrel, and 1.0% dipyridamole. The recording of any complication of a sharp needle or subtenon's cannula local anaesthetic block was increased in patients taking clopidogrel, 8.0% (P<0.0001) or warfarin, 6.2% (P=0.0026) vs non-users, 4.3%, but no increase in potentially sight-threatening complications was identified. The incidence of subconjunctival haemorrhage was increased in patients taking clopidogrel, 4.4% (P<0.0001) or warfarin, 3.7% (P<0.0001) vs non-users, 1.7%. The recording of any operative complication was increased in those taking clopidogrel, 7.3% (P=0.0002) vs non-users, 4.4%, but the haemorrhagic operative complications of choroidal/suprachoroidal haemorrhage and hyphaema were not significantly increased. The non-haemorrhagic complication of posterior capsular rupture (PCR) was increased in those taking clopidogrel, 3.23% (P=0.0057) vs non-users, 1.77%.

• CONCLUSIONS: Clopidogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and subtenon's cannula local anaesthesia but was not associated with a significant increase in potentially sight-threatening local anaesthetic or operative haemorrhagic complications

Anesthesia Costing;calcolo in euro/mg per circa 20 min di intervento

• Midazolam 16.3 euro mg/10 fl da 5 mg=0.32 al mg

• Fentanest:3.10/ 5 fl/500 microgr =0.0062/microgr

• Catapresan cp 30 da 300 mg5.60:

• Sedazione per un adulto di 70 kg:3mg di midaz,75 microgr di fentanest=

• 0.96 eruro per midaz+0,465 per fentanes:arrotondiamo a 1,5 euro

• Propofol :48.23 /5 fl all1% cioè 100 ml=1ooo mg=0.00483/mg

• Remifentanil 46.40/5 flac da 1mg=0.00928 al microgr

• Sedazione per un un adulto di 70 kg35 mg dipropof +3 mg/kg per 20 min =210/h=70 mg=0.17+0.33=0.50+0.55=1 euro

sedazione di circa 30 min

• Midazolam:1 fl =1,63 euro• Fentanest 1 fiala=0.62

euro

• Propofol 1 fl=9,64• Remif 1 mg=9,28

Vantaggi e svantaggi di uno e altro• Il propofol una volta aperto non si può lasciare;bisogna

consumarlo o buttare(intralipid...)• Il remifentanil una volta diluito 1 mg e utilizzato 60-70 microgr,che

si fa del resto?• Remif va diluito e infuso in pompa siringa.....• Problemi della cinetica....• Vogliamo parlare dei tempi di ripresa dei pazienti?• Possiamo calcolare i costi della permanenza nella saletta fino alla

street fitness?• Possiamo calcolare quanto occorre per l’anestesista a preparare gli

uni e gli altri? E l’esperienza necessaria?e il margine di sicurezza?

The pursuit of perfection • Ideas for a perfect matching among surgery

requirements and patient satisfaction and safety • Oral antibiotics and sedation (???)• Topical• Microbolus of midaz• (Propofol cont infus)• Remif microboluses/fentanyl boluses.• Monitoring NIBP,ECG,SaO2,etCO2,EEG CSM,Ramsey• isas

Eye. 1999 Apr;13 ( Pt 2):196-204. Comment in: Eye. 1999 Dec;13 ( Pt 6):810-1. The National Survey of Local Anaesthesia for Ocular Surgery. II.

Safety profiles of local anaesthesia techniques.Eke T, Thompson JR.Sub-Committee Royal College of Ophthalmologists, London, UK.

• reported incidence of all adverse events within the orbit 2.7%• systemic' adverse events 0.9%. • Serious adverse events were reported in association with all LA techniques. • In 3 months, 18 events were described as 'life-threatening' by

respondents, and further patients were reported to have had epileptic fits or were transferred directly from the operating theatre to an intensive care

unit. Serious adverse events were reported in association with all LA techniques. This implies that we should be prepared for such events in all patients who have intraocular surgery.

The Cataract National Dataset electronic multi-centre audit of 55,567 operations: updating benchmark standards of care in the United Kingdom and internationally.Jaycock P,

Johnston RL, Taylor H, Adams M, Tole DM, Galloway P, Canning C, Sparrow JM; UK EPR user groupEye. 2009 Jan;23(1):38-49. Epub 2007 Nov 23.

• 406 surgeons,12 trusts • 55,567 cataract operations between November

2001 and July 2006 (86% from January 2004)• Complication rates : – posterior capsule rupture and/or vitreous loss

1.92%– simple zonule dialysis 0.46% – retained lens fragments 0.18%.

Carla R.57 a,71 kg,ASA 2

Mg/h

Microgr/h

Breaths/min

mmHg

INFECTION(SSI) CONTROL POLICIES

• J Perianesth Nurs. 2001 Dec;16(6):379-87.• Fast-tracking after ambulatory surgery.• Watkins AC1, White PF.• Author information

• Abstract• The fast-tracking recovery concept examines different paradigms for streamlining the postoperative recovery

process. Fast-tracking anesthetic techniques allow suitable outpatients to be discharged earlier after ambulatory surgery. Outpatients are normally transferred from the OR to the PACU, followed by transfer to the Phase II step-down (day-surgery unit) before discharge home. With conventional fast-tracking, it is possible to bypass the PACU and take patients directly from the OR to the step-down unit if they meet specific criteria before leaving the OR. Alternatively, if the step-down unit is already functioning at maximum capacity, the PACU can be restructured to include a fast-track area, where appropriate patients are treated as if they had been admitted directly to the step-down unit. For these PACU fast-track patients, less monitoring is performed, a family member is permitted to be with the patient, and the patient is allowed to ambulate, change into street clothes, and be discharged home directly from the PACU without any time restrictions. Preliminary studies have shown that outpatients who are fast-tracked can be discharged home earlier without any increase in complications or side effects. Importantly, fast-tracking after ambulatory surgery does not seem to compromise patient satisfaction with the surgical experience

• Ann Surg. 2014 Mar;259(3):591-7. doi: 10.1097/SLA.0b013e3182a6f2d9.• Glove and gown effects on intraoperative bacterial contamination.• Ward WG Sr1, Cooper JM, Lippert D, Kablawi RO, Neiberg RH, Sherertz RJ.• Author information

• Abstract• OBJECTIVE:• Experiments were performed to determine the risk of bacterial contamination associated with changing outer gloves and using disposable spunlace paper versus

reusable cloth gowns.• BACKGROUND:• Despite decades of research, there remains a lack of consensus regarding certain aspects of optimal aseptic technique including outer glove EXCHANGE while

double-gloving and surgical gown type selection.• METHODS:• In an initial glove study, 102 surgical team members were randomized to EXCHANGE or retain outer gloves 1 hour into clean orthopedic procedures; cultures were

obtained 15 minutes later from the palm of the surgeon's dominant gloved hand and from the surgical gown sleeve. Surgical gown type selection was recorded. A laboratory strike-through study investigating bacterial transmission through cloth and paper gowns was performed with coagulase-negative staphylococci. In a follow-up glove study, 251 surgical team members, all wearing paper gowns, were randomized as in the first glove study.

• RESULTS:• Glove study 1 revealed 4-fold higher levels of baseline bacterial contamination (31% vs 7%) on the sleeve of surgical team members wearing cloth gowns than

those using paper gowns [odds ratio (95% confidence interval): 4.64 (1.72-12.53); P = 0.0016]. The bacterial strike-through study revealed that 26 of 27 cloth gowns allowed bacterial transmission through the material compared with 0 of 27 paper gowns (P < 0.001). In glove study 2, surgeons retaining outer gloves 1 hour into the case had a subsequent positive glove contamination rate of 23% compared with 13% among surgeons exchanging their original outer glove [odds ratio (95% confidence interval): 1.97 (1.02-3.80); P = 0.0419].

• CONCLUSIONS:• Paper gowns demonstrated less bacterial transmission in the laboratory and lower rates of contamination in the operating room. Disposable paper gowns are

recommended for all surgical cases, especially those involving implants, because of the heightened risk of infection. Outer glove exchange just before handling implant materials is also recommended to minimize intraoperative contamination

• Anesth Analg. 2012 May;114(5):1055-66. doi: 10.1213/ANE.0b013e31824d9cc3. Epub 2012 Apr 4.• A comparison of reusable and disposable perioperative textiles: sustainability state-of-the-art 2012.• Overcash M.• Author information

• Erratum in• Anesth Analg. 2012 Sep;115(3):733.• Abstract• Contemporary comparisons of reusable and single-use perioperative textiles (surgical gowns and drapes) reflect major changes in the

technologies to produce and reuse these products. Reusable and disposable gowns and drapes meet new standards for medical workers and patient protection, use synthetic lightweight fabrics, and are competitively priced. In multiple science-based life cycle environmental studies, reusable surgical gowns and drapes demonstrate substantial sustainability benefits over the same disposable product in natural resource energy (200%-300%), water (250%-330%), carbon footprint (200%-300%), volatile organics, solid wastes (750%), and instrument recovery. Because all other factors (cost, protection, and comfort) are reasonably similar, the environmental benefits of reusable surgical gowns and drapes to health care sustainability programs are important for this industry. Thus, it is no longer valid to indicate that reusables are better in some environmental impacts and disposables are better in other environmental impacts. It is also important to recognize that large-scale studies of comfort, protection, or economics have not been actively pursued in the last 5 to 10 years, and thus the factors to improve both reusables and disposable systems are difficult to assess. In addition, the comparison related to jobs is not well studied, but may further support reusables. In summary, currently available perioperative textiles are similar in comfort, safety, and cost, but reusable textiles offer substantial opportunities for nurses, physicians, and hospitals to reduce environmental footprints when selected over disposable alternatives. Evidenced-based comparison of environmental factors supports the conclusion that reusable gowns and drapes offer important sustainability improvements. The benefit of reusable systems may be similar for other reusables in anesthesia, such as laryngeal mask airways or suction canisters, but life cycle studies are needed to substantiate these benefits.

• Nurs Stand. 1997 Jul 16;11(43):44-6.• Wedding rings and hospital-acquired infection.• Bernthal E.• Author information

• Abstract• Some theatre nurses are reluctant to remove their wedding

rings when scrubbing up. This article reviews the literature and concludes that keeping rings on may put the patient at risk of nosocomial (hospital-acquired) infection

Paziente anziano che si tira su all’improvviso bestemmiando quando il prof lo punge!!!!

Professional relationshipAt a medical convention, a male doctor and a female doctor start eyeing each other.The male doctor asks her to dinner and she accepts. As they sit down at the restaurant, she excuses herself to go and wash her hands. After dinner, one thing leads to another and they end up in her hotel bedroom. Just as things get hot, the female doctor interrupts and says she has to go and wash her hands. Once she comes back they go for it. After the sex session, she gets up and says she is going to wash her hands. As she comes back the male doctor says, "I bet you are a surgeon".She confirms and asks how he knew. "Easy, you're always washing your hands."She then says, "I bet you're an anesthesiologist."Male doctor: "Wow, how did you guess?"Female doctor: "I didn't feel a thing."

Easiests intubation in the world

Labour pain

This meant for anesthetic

departments that are trying to cut

costs by limiting use of anesthetic agents. This vaporiser needs

you to put in your credit card. As you increase the fresh

gas flow through the vaporiser, the flow

of money out of your bank account

also increases.

• Dedicated to all ANESTHETISTS• What role does the anesthetist play?• Most operations today require some form of anesthesia. I'm an important member

of the surgical team. I render you unconscious or insensitive to pain during surgery, and carefully observes your vital signs, such as blood pressure, pulse, and respiration, throughout the procedure.

• In addition to working in the operating room, I also work in pain clinics, obstetrical wards and intensive care units.

• I reduce your pain.I take care of your pulse.I always keep an eye on your ECG ...I take care of your breath..I resuscitated your heart when it goes to arrest. I try my best to make you revive.

• I too work hard as other many doctors do... Many times I go unrecognised, but I know for whom Im working.

• I work for the people, not for the name and fame.• I'm the ANESTHETIST

Anesthesia In The Olden DaysMeet Your Anesthesiologist

• http://www.toilette-humor.com/images/medical/meet_anesthesiologist.jpg

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